Provider Demographics
NPI:1972531523
Name:BERGEN GASTROENTEROLOGY PC
Entity Type:Organization
Organization Name:BERGEN GASTROENTEROLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/MD
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:S
Authorized Official - Last Name:AVEZZANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-967-8221
Mailing Address - Street 1:466 OLD HOOK RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:EMERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07630-1396
Mailing Address - Country:US
Mailing Address - Phone:201-967-8221
Mailing Address - Fax:
Practice Address - Street 1:466 OLD HOOK RD
Practice Address - Street 2:SUITE 1
Practice Address - City:EMERSON
Practice Address - State:NJ
Practice Address - Zip Code:07630-1396
Practice Address - Country:US
Practice Address - Phone:201-967-8221
Practice Address - Fax:201-634-9647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ465837207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ=========OtherTAX ID#
NJ=========OtherTAX ID#