Provider Demographics
NPI:1619244514
Name:BRIDGE MEDICAL CENTER PROFESSIONAL ASSOCIATION
Entity Type:Organization
Organization Name:BRIDGE MEDICAL CENTER PROFESSIONAL ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:MAZZACCARO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-729-0016
Mailing Address - Street 1:4 SOUTHWOODS LN
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07438-9848
Mailing Address - Country:US
Mailing Address - Phone:973-729-0016
Mailing Address - Fax:973-729-0058
Practice Address - Street 1:351 SPARTA AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:SPARTA
Practice Address - State:NJ
Practice Address - Zip Code:07871-1160
Practice Address - Country:US
Practice Address - Phone:973-729-0016
Practice Address - Fax:973-729-0058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-19
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07206600207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJH48753Medicare UPIN