Provider Demographics
NPI:1154595197
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 1:136 HOPPER AVE.
Mailing Address - Street 2:
Mailing Address - City:WALDWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:07463
Mailing Address - Country:US
Mailing Address - Phone:201-488-0488
Mailing Address - Fax:
Practice Address - Street 1:136 HOPPER AVE.
Practice Address - Street 2:
Practice Address - City:WALDWICK
Practice Address - State:NJ
Practice Address - Zip Code:07463
Practice Address - Country:US
Practice Address - Phone:201-488-0488
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ044081OtherLEGACY