1518977974 NPI number — MARK BERMAN D.P.M.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518977974 NPI number — MARK BERMAN D.P.M.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARK BERMAN D.P.M.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518977974
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2402 E HARBOR RIDGE WAY
Provider Second Line Business Mailing Address:
SUITE E
Provider Business Mailing Address City Name:
LINDENHURST
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60046-4911
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-245-4100
Provider Business Mailing Address Fax Number:
847-245-4420

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10024 SKOKIE BLVD
Provider Second Line Business Practice Location Address:
SUITE 303
Provider Business Practice Location Address City Name:
SKOKIE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60077-9944
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-674-1660
Provider Business Practice Location Address Fax Number:
847-674-2688
Provider Enumeration Date:
08/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BERMAN
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
PODIATRIST/OWNER
Authorized Official Telephone Number:
847-674-1660

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  16003176 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 016003176 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com