Provider Demographics
NPI:1316020662
Name:BERGEN AMBULATORY ANESTHESIA
Entity Type:Organization
Organization Name:BERGEN AMBULATORY ANESTHESIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:AVEZZANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-967-2455
Mailing Address - Street 1:PO BOX 34546
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07189-0001
Mailing Address - Country:US
Mailing Address - Phone:201-967-2455
Mailing Address - Fax:201-634-9647
Practice Address - Street 1:466 OLD HOOK RD
Practice Address - Street 2:SUITE 19
Practice Address - City:EMERSON
Practice Address - State:NJ
Practice Address - Zip Code:07630-1396
Practice Address - Country:US
Practice Address - Phone:201-967-2455
Practice Address - Fax:201-634-9647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty