Provider Demographics
NPI:1669495099
Name:BERGEN MEDICAL ALLIANCE PA
Entity Type:Organization
Organization Name:BERGEN MEDICAL ALLIANCE PA
Other - Org Name:BERGEN MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MASIELLO
Authorized Official - Suffix:
Authorized Official - Credentials:CMPE
Authorized Official - Phone:201-567-2050
Mailing Address - Street 1:180 ENGLE ST
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-2507
Mailing Address - Country:US
Mailing Address - Phone:201-567-2050
Mailing Address - Fax:201-567-5070
Practice Address - Street 1:180 ENGLE ST
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-2507
Practice Address - Country:US
Practice Address - Phone:201-567-2050
Practice Address - Fax:201-567-5070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
877421Medicare PIN