Provider Demographics
NPI:1164654018
Name:BRIDGESIDE MEDICAL PC
Entity Type:Organization
Organization Name:BRIDGESIDE MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:
Authorized Official - Last Name:REZVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-863-3711
Mailing Address - Street 1:441 WILFRED TER
Mailing Address - Street 2:
Mailing Address - City:CLIFFSIDE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07010-1401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:441 WILFRED TER
Practice Address - Street 2:
Practice Address - City:CLIFFSIDE PARK
Practice Address - State:NJ
Practice Address - Zip Code:07010-1401
Practice Address - Country:US
Practice Address - Phone:845-863-3711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-11
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
NJ25MA08029100207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY200SQ1Medicare PIN
NY25MA08029100OtherLICENSE
NY200SQ1Medicaid
NYYR02176U20OtherBCBS