Provider Demographics
NPI:1952761363
Name:BERGEN FOOT & ANKLE GROUP LLC
Entity Type:Organization
Organization Name:BERGEN FOOT & ANKLE GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:SEESE-KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:201-944-4477
Mailing Address - Street 1:2175 LEMOINE AVE STE 302
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-6019
Mailing Address - Country:US
Mailing Address - Phone:201-944-4477
Mailing Address - Fax:
Practice Address - Street 1:2175 LEMOINE AVE STE 302
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-6019
Practice Address - Country:US
Practice Address - Phone:201-944-4477
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-26
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD2346213ES0103X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7445903Medicaid
NJ7445903Medicaid
NJU62252Medicare UPIN
NJSE883781Medicare PIN