1215999115 NPI number — DR. JACK M BERDY M.D.

Table of content: DR. JACK M BERDY M.D. (NPI 1215999115)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215999115 NPI number — DR. JACK M BERDY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERDY
Provider First Name:
JACK
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1215999115
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
155 CEDAR LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEANECK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07666-4301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-836-4248
Provider Business Mailing Address Fax Number:
201-836-5420

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
155 CEDAR LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEANECK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07666-4301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-836-4248
Provider Business Practice Location Address Fax Number:
201-836-5420
Provider Enumeration Date:
04/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  MA60816 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0853523000 . This is a "AMERIHEALTH#" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: P00332714 . This is a "RAILROAD MEDICARE #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0125870 . This is a "GHI PPO#" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 3K3825 . This is a "HEALTHNET#" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0479230 . This is a "AETNA HMO #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 230SB2 . This is a "EMPIRE BC/BS #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 6925201 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: P3688668 . This is a "OXFORD #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0479230 . This is a "AETNA PPO#" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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