Provider Demographics
NPI:1245357276
Name:ERIC BENTOLILA, M.D. PA
Entity type:Organization
Organization Name:ERIC BENTOLILA, M.D. PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CLARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:VEGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-874-8459
Mailing Address - Street 1:150 FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-3206
Mailing Address - Country:US
Mailing Address - Phone:201-447-1700
Mailing Address - Fax:201-447-9386
Practice Address - Street 1:615 FRANKLIN TURNPIKE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-0745
Practice Address - Country:US
Practice Address - Phone:201-447-1700
Practice Address - Fax:201-447-9386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07057600174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2371713000OtherAMERIHEALTH GROUP#