1952387516 NPI number — WALLACE P BERKOWITZ MD LTD

Table of content: (NPI 1952387516)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952387516 NPI number — WALLACE P BERKOWITZ MD LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WALLACE P BERKOWITZ MD LTD
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:
1952387516
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6651 CHIPPEWA
Provider Second Line Business Mailing Address:
STE 324
Provider Business Mailing Address City Name:
ST LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63109-2538
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-647-8895
Provider Business Mailing Address Fax Number:
314-647-8898

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6651 CHIPPEWA
Provider Second Line Business Practice Location Address:
STE 324
Provider Business Practice Location Address City Name:
ST LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63109-2538
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-647-8895
Provider Business Practice Location Address Fax Number:
314-647-8898
Provider Enumeration Date:
12/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BERKOWITZ
Authorized Official First Name:
WALLACE
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PRESIDENT OWNER
Authorized Official Telephone Number:
314-647-8895

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X , with the licence number:  R4234 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Y00000X , 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: 100287 . This is a "HEALTHPARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: M2229 . This is a "MO MCR SUBMITTER ID" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 08200436 . This is a "BCBS OF IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 2230168 . This is a "AETNA HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4376271 . This is a "AETNA PPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6670 . This is a "BLUE CHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6670 . This is a "ALLIANCE ALL CHOICE BASIC" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: R4234 . This is a "MO LICENSE NUMBER" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 1007077 . This is a "UHC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 119451 . This is a "HEALTHLINK" identifier . This identifiers is of the category "OTHER".




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