Provider Demographics
NPI:1750302683
Name:BERGEN PEDIATRIC CENTER,P.C
Entity Type:Organization
Organization Name:BERGEN PEDIATRIC CENTER,P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OMANA
Authorized Official - Middle Name:REJI
Authorized Official - Last Name:MATHEW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-384-8510
Mailing Address - Street 1:167 S WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BERGENFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07621-2903
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:167 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:BERGENFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07621-2903
Practice Address - Country:US
Practice Address - Phone:201-384-8510
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA061019208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty