Basic Information
Provider Information | |||||||||
NPI: | 1265427405 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BERLAND | ||||||||
FirstName: | GREGORY | ||||||||
MiddleName: | A | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2410 NORTHSIDE DR | ||||||||
Address2: |   | ||||||||
City: | CLEARWATER | ||||||||
State: | FL | ||||||||
PostalCode: | 337612236 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7277711300 | ||||||||
FaxNumber: | 7277813312 | ||||||||
Practice Location | |||||||||
Address1: | 11663 COUNTRYWAY BLVD | ||||||||
Address2: |   | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 336262739 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8138916310 | ||||||||
FaxNumber: | 8138916889 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/14/2005 | ||||||||
LastUpdateDate: | 01/25/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME83697 | FL | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 4441393 | 01 | FL | CIGNA | OTHER | 1048101 | 01 | FL | CAREPLUS | OTHER | 04896 | 01 | FL | UNIVERSAL | OTHER | 289697 | 01 | FL | AVMED | OTHER | 15336 | 01 | FL | BCBS INDIVIDUAL | OTHER | 267002000 | 05 | FL |   | MEDICAID | 7230565 | 01 | FL | AETNA | OTHER |