Provider Demographics
NPI:1811207475
Name:BERGENLINE FAMILY MEDICINE
Entity Type:Organization
Organization Name:BERGENLINE FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GIL
Authorized Official - Middle Name:V
Authorized Official - Last Name:FAJARDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-453-8777
Mailing Address - Street 1:333 60TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST NEW YORK
Mailing Address - State:NJ
Mailing Address - Zip Code:07093-5487
Mailing Address - Country:US
Mailing Address - Phone:201-453-8777
Mailing Address - Fax:201-453-8804
Practice Address - Street 1:333 60TH ST
Practice Address - Street 2:
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093-5487
Practice Address - Country:US
Practice Address - Phone:201-453-8777
Practice Address - Fax:201-453-8804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-18
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA062055261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJG37823OtherUPIN
NJ7003803Medicaid
NJ7003803Medicaid