Provider Demographics
NPI:1124470786
Name:BERGEN SPINE ASSOCIATES
Entity type:Organization
Organization Name:BERGEN SPINE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KOSIBOROD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-880-6204
Mailing Address - Street 1:50 CLINTON PL STE 6
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-4580
Mailing Address - Country:US
Mailing Address - Phone:201-880-6204
Mailing Address - Fax:201-880-6206
Practice Address - Street 1:50 CLINTON PL STE 6
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-4580
Practice Address - Country:US
Practice Address - Phone:201-880-6204
Practice Address - Fax:201-880-6206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-07
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07566200261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care