Basic Information
| Provider Information | |||||||||
| NPI: | 1295799294 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERGER | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D., | ||||||||
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| Mailing Information | |||||||||
| Address1: | 222 STATION PLZ N | ||||||||
| Address2: | SUITE 518 | ||||||||
| City: | MINEOLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115013808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166632588 | ||||||||
| FaxNumber: | 5166634644 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 STATION PLZ N | ||||||||
| Address2: | SUITE 518 | ||||||||
| City: | MINEOLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115013808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166632588 | ||||||||
| FaxNumber: | 5166634644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2006 | ||||||||
| LastUpdateDate: | 02/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173000000X | 179152 | NY | N | Other Service Providers | Legal Medicine | 207R00000X | 179152 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0002X | 179152 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01352354 | 05 | NY | MEDICAID |