Provider Demographics
NPI:1710060314
Name:BERNARD HENSON
Entity Type:Organization
Organization Name:BERNARD HENSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:
Authorized Official - Last Name:HENSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-904-1704
Mailing Address - Street 1:220 HAMBURG TPKE STE 18A
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-2132
Mailing Address - Country:US
Mailing Address - Phone:973-904-1704
Mailing Address - Fax:973-595-8741
Practice Address - Street 1:220 HAMBURG TPKE STE 18A
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-2132
Practice Address - Country:US
Practice Address - Phone:973-904-1704
Practice Address - Fax:973-595-8741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA03972500208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3315207Medicaid
NJ3315207Medicaid
NJHE520303Medicare ID - Type Unspecified