Provider Demographics
NPI:1598781973
Name:BLOOMFIELD HEALTH PAVILION LLC
Entity type:Organization
Organization Name:BLOOMFIELD HEALTH PAVILION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROSTISLAV
Authorized Official - Middle Name:
Authorized Official - Last Name:VILSHTEYN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-813-4556
Mailing Address - Street 1:86 BLOOMFIELD AVE
Mailing Address - Street 2:1ST FLOOR & BASEMENT
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104-1905
Mailing Address - Country:US
Mailing Address - Phone:973-230-3631
Mailing Address - Fax:973-230-3474
Practice Address - Street 1:86 BLOOMFIELD AVE
Practice Address - Street 2:1ST FLOOR & BASEMENT
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07104-1905
Practice Address - Country:US
Practice Address - Phone:973-230-3631
Practice Address - Fax:973-230-3474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ051A267103TA0400X, 103TA0700X, 103TB0200X, 103TC1900X, 103TC2200X, 103T00000X, 103TP2701X, 103TR0400X
NJ363L00000X, 363LC1500X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty
Not Answered103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & AgingGroup - Multi-Specialty
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Not Answered103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty
Not Answered103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitationGroup - Multi-Specialty
Not Answered363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Not Answered363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity HealthGroup - Multi-Specialty
Not Answered363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ=========OtherMULTI SPECIALTY