Provider Demographics
NPI:1467757708
Name:MEDICAL GROUP OF BERGEN PC
Entity Type:Organization
Organization Name:MEDICAL GROUP OF BERGEN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARUTYUNYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-225-4700
Mailing Address - Street 1:28 WOODCREST DR
Mailing Address - Street 2:
Mailing Address - City:WOODCLIFF LAKE
Mailing Address - State:NJ
Mailing Address - Zip Code:07677-7628
Mailing Address - Country:US
Mailing Address - Phone:201-362-3978
Mailing Address - Fax:201-458-9933
Practice Address - Street 1:230 E RIDGEWOOD AVE
Practice Address - Street 2:BLDG 6, SECOND FLOOR
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-4142
Practice Address - Country:US
Practice Address - Phone:201-225-4700
Practice Address - Fax:201-225-4702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-18
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08285000207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0206512Medicaid
NJ208703Medicare PIN
NJ208703Medicare PIN