=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992109334
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BERGENFIELD SURGICAL CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2014
-----------------------------------------------------
Last Update Date | 07/28/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 N WASHINGTON AVE SUITE A
-----------------------------------------------------
City | BERGENFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07621-2125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-374-2829
-----------------------------------------------------
Fax | 201-374-2835
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 N WASHINGTON AVE SUITE A
-----------------------------------------------------
City | BERGENFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07621-2125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-374-2829
-----------------------------------------------------
Fax | 201-374-2835
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | WENDY CONDO
-----------------------------------------------------
Credential | RN, BSN
-----------------------------------------------------
Telephone | 201-374-2829
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------