Provider Demographics
NPI:1477502078
Name:NEW JERSEY BREAST DIAGNOSTIC CENTER, PA
Entity Type:Organization
Organization Name:NEW JERSEY BREAST DIAGNOSTIC CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BERTRAM
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:WEISS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-444-4412
Mailing Address - Street 1:145 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-4493
Mailing Address - Country:US
Mailing Address - Phone:201-444-4412
Mailing Address - Fax:201-444-6966
Practice Address - Street 1:145 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-4493
Practice Address - Country:US
Practice Address - Phone:201-444-4412
Practice Address - Fax:201-444-6966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJD07130Medicare UPIN
NJNE527200Medicare ID - Type Unspecified