Provider Demographics
NPI:1801134804
Name:SPORTS MEDICINE CENTER OF BERGEN, PA
Entity type:Organization
Organization Name:SPORTS MEDICINE CENTER OF BERGEN, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:FLINK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:201-488-0488
Mailing Address - Street 1:605 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-5914
Mailing Address - Country:US
Mailing Address - Phone:201-488-0488
Mailing Address - Fax:
Practice Address - Street 1:15 S KINDERKAMACK RD
Practice Address - Street 2:
Practice Address - City:MONTVALE
Practice Address - State:NJ
Practice Address - Zip Code:07645-2112
Practice Address - Country:US
Practice Address - Phone:201-573-4969
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-25
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ044081Medicare UPIN