Basic Information
| Provider Information | |||||||||
| NPI: | 1841650330 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEMORIAL SLOAN KETTERING BERGEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1275 YORK AVE | ||||||||
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| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100656007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2126392000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 225 SUMMIT AVE | ||||||||
| Address2: | |||||||||
| City: | MONTVALE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076451523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2126392000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2016 | ||||||||
| LastUpdateDate: | 04/22/2016 | ||||||||
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| AuthorizedOfficialLastName: | MARTIN | ||||||||
| AuthorizedOfficialFirstName: | KATHRYN | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 2126392623 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEMORIAL HOSPITAL FOR CANCER & ALLIED DISEASES | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 24973 | NJ | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 00243467 | 05 | NY | MEDICAID |