Provider Demographics
NPI:1679770952
Name:BERGEN KIDNEY CENTER
Entity type:Organization
Organization Name:BERGEN KIDNEY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REVENUE CYCLE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHARISSE
Authorized Official - Middle Name:
Authorized Official - Last Name:PHIPPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-974-5236
Mailing Address - Street 1:300 GRAND AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-4398
Mailing Address - Country:US
Mailing Address - Phone:201-567-5787
Mailing Address - Fax:201-567-7652
Practice Address - Street 1:300 GRAND AVENUE
Practice Address - Street 2:SUITE 101
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-6581
Practice Address - Country:US
Practice Address - Phone:201-567-5787
Practice Address - Fax:201-567-7652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-29
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA057981207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6097201Medicaid
NJ722425Medicare ID - Type Unspecified
NJE97238Medicare UPIN