Provider Demographics
NPI:1538759394
Name:BERGEN PHYSICAL & VEIN MEDICINE LLC
Entity type:Organization
Organization Name:BERGEN PHYSICAL & VEIN MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEKSANDR
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIROSOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-450-5125
Mailing Address - Street 1:323 BERGEN BLVD
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:NJ
Mailing Address - Zip Code:07022-1334
Mailing Address - Country:US
Mailing Address - Phone:201-283-4363
Mailing Address - Fax:551-264-9558
Practice Address - Street 1:323 BERGEN BLVD
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:NJ
Practice Address - Zip Code:07022-1334
Practice Address - Country:US
Practice Address - Phone:201-283-4363
Practice Address - Fax:551-264-9558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-25
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty