Provider Demographics
NPI:1063566636
Name:BERGEN MEDICAL GROUP, P.C.
Entity type:Organization
Organization Name:BERGEN MEDICAL GROUP, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BLAIR
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:BERGEN
Authorized Official - Suffix:I
Authorized Official - Credentials:MD
Authorized Official - Phone:609-484-1001
Mailing Address - Street 1:26 WILSON DR
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:08225-2569
Mailing Address - Country:US
Mailing Address - Phone:609-484-1001
Mailing Address - Fax:609-484-1004
Practice Address - Street 1:233 W ABSECON BLVD
Practice Address - Street 2:
Practice Address - City:ABSECON
Practice Address - State:NJ
Practice Address - Zip Code:08201-2403
Practice Address - Country:US
Practice Address - Phone:609-484-1001
Practice Address - Fax:609-484-1004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04675800207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7850905Medicaid