1992850879 NPI number — STEPHEN C BERENS, MD A MED. CORP.

Table of content: (NPI 1992850879)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992850879 NPI number — STEPHEN C BERENS, MD A MED. CORP.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STEPHEN C BERENS, MD A MED. CORP.
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:
1992850879
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
POB 261037
Provider Second Line Business Mailing Address:
SUITE 268W
Provider Business Mailing Address City Name:
ENCINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91426-1037
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-828-4633
Provider Business Mailing Address Fax Number:
310-828-6205

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1301 20TH ST.
Provider Second Line Business Practice Location Address:
SUITE 590
Provider Business Practice Location Address City Name:
SANTA MONICA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-828-4633
Provider Business Practice Location Address Fax Number:
818-784-5639
Provider Enumeration Date:
01/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BERENS
Authorized Official First Name:
ROBERTA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
VICE PRE & SEC. OF CORPORATION
Authorized Official Telephone Number:
310-828-4633

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  A22556 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X , with the licence number: A-22556 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1528050408 . This is a "PERSONAL NATIONAL PROVIDE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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