Basic Information
Provider Information | |||||||||
NPI: | 1013996255 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BERKOWITZ | ||||||||
FirstName: | PAUL | ||||||||
MiddleName: | I | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 601 JOHN STREET | ||||||||
Address2: | SUITE N1200 | ||||||||
City: | KALAMAZOO | ||||||||
State: | MI | ||||||||
PostalCode: | 490075341 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2693417979 | ||||||||
FaxNumber: | 2693416261 | ||||||||
Practice Location | |||||||||
Address1: | 601 JOHN STREET | ||||||||
Address2: | BOX 42 | ||||||||
City: | KALAMAZOO | ||||||||
State: | MI | ||||||||
PostalCode: | 490075341 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2693416417 | ||||||||
FaxNumber: | 2693418743 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/16/2006 | ||||||||
LastUpdateDate: | 02/08/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/08/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0201X | 036112040 | IL | N |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology | 207V00000X | 4301087318 | MI | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 4852967 | 05 | MI |   | MEDICAID | 5700239 | 01 | IL | BCBS GROUP NUMBER | OTHER | 036112040 | 05 | IL |   | MEDICAID | K11241 | 01 |   | PIN | OTHER |