Provider Demographics
NPI:1326341033
Name:SPARTACO BELLOMO M.D.P.A.
Entity Type:Organization
Organization Name:SPARTACO BELLOMO M.D.P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SOPHIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CISZEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:201-653-8336
Mailing Address - Street 1:142 PALISADE AVENUE
Mailing Address - Street 2:SUITE 209
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-1108
Mailing Address - Country:US
Mailing Address - Phone:201-653-8336
Mailing Address - Fax:201-653-6697
Practice Address - Street 1:142 PALISADE AVE
Practice Address - Street 2:SUITE 209
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-1133
Practice Address - Country:US
Practice Address - Phone:201-653-8336
Practice Address - Fax:201-653-6697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-20
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03988000174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1425706Medicaid
NJ1425706Medicaid