Basic Information
| Provider Information | |||||||||
| NPI: | 1366734535 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPORTS MEDICINE CENTER OF BERGEN, PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EXCEL ORTHOPEDIC REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 605 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HACKENSACK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076015914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2014880488 | ||||||||
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| Practice Location | |||||||||
| Address1: | 301 ROUTE 17 | ||||||||
| Address2: | |||||||||
| City: | RUTHERFORD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070702575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2014600032 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2011 | ||||||||
| LastUpdateDate: | 05/24/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FLINK | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2014880488 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | P.T. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.