Basic Information
| Provider Information | |||||||||
| NPI: | 1194816249 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BERGEN ANESTHESIA GROUP, P.C. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 500 W MAIN ST | ||||||||
| Address2: | SUITE 16 | ||||||||
| City: | WYCKOFF | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074811439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018479320 | ||||||||
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| Practice Location | |||||||||
| Address1: | 223 N VAN DIEN AVE | ||||||||
| Address2: | OPERATING ROOM | ||||||||
| City: | RIDGEWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074502726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018479403 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SCOGNAMIGLIO | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2018479320 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 7035101 | 05 | NJ | MEDICAID |