Provider Demographics
NPI:1336373539
Name:BERGEN INTERNAL MEDICINE LLC
Entity Type:Organization
Organization Name:BERGEN INTERNAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:JUSTIN
Authorized Official - Last Name:GALLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-886-8989
Mailing Address - Street 1:6 HORIZON RD
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-6652
Mailing Address - Country:US
Mailing Address - Phone:201-886-8989
Mailing Address - Fax:201-886-8990
Practice Address - Street 1:6 HORIZON RD
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-6652
Practice Address - Country:US
Practice Address - Phone:201-886-8989
Practice Address - Fax:201-886-8990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-04
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA54263207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4992806Medicaid
NJE62864Medicare UPIN
NJ682135C78Medicare PIN