Provider Demographics
NPI:1255198776
Name:MB ADVANCED WOUND CARE
Entity type:Organization
Organization Name:MB ADVANCED WOUND CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGAMOTTO
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:973-715-9939
Mailing Address - Street 1:25 GOULD PL
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07006-5609
Mailing Address - Country:US
Mailing Address - Phone:973-715-9939
Mailing Address - Fax:
Practice Address - Street 1:25 GOULD PL
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:NJ
Practice Address - Zip Code:07006-5609
Practice Address - Country:US
Practice Address - Phone:973-715-9939
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-01
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty