Provider Demographics
NPI:1881775658
Name:BERGEN, BLAIR ALEXANDER (MD)
Entity type:Individual
Prefix:
First Name:BLAIR
Middle Name:ALEXANDER
Last Name:BERGEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 ENGLISH CREEK AVE
Mailing Address - Street 2:BLDG 200 SUITE214
Mailing Address - City:EGG HARBOR TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08234-5549
Mailing Address - Country:US
Mailing Address - Phone:609-677-7211
Mailing Address - Fax:609-677-7210
Practice Address - Street 1:2500 ENGLISH CREEK AVE
Practice Address - Street 2:BLDG 200 SUITE214
Practice Address - City:EGG HARBOR TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08234-5549
Practice Address - Country:US
Practice Address - Phone:609-677-7211
Practice Address - Fax:609-677-7210
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA04675800207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3612007Medicaid
NJ541427CN9Medicare PIN
NJ541427SBVMedicare PIN
NJC54296Medicare UPIN
NJ3612007Medicaid