1669490777 NPI number — MR. GARY M BERKE MS, CP

Table of content: MR. GARY M BERKE MS, CP (NPI 1669490777)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669490777 NPI number — MR. GARY M BERKE MS, CP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERKE
Provider First Name:
GARY
Provider Middle Name:
M
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MS, CP
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:
1669490777
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2001 WINWARD WAY
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
SAN MATEO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94404-2499
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-365-5861
Provider Business Mailing Address Fax Number:
650-365-5896

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2001 WINWARD WAY
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
SAN MATEO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94404-2499
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-365-5861
Provider Business Practice Location Address Fax Number:
650-365-5896
Provider Enumeration Date:
07/17/2006

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: 222Z00000X , with the licence number:  CP1628 ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 224P00000X , with the licence number: CP1628 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: XB0016280 . This is a "MEDICAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: XB0016280 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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