Basic Information
| Provider Information | |||||||||
| NPI: | 1407942006 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERSON | ||||||||
| FirstName: | LAWRENCE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 410 SAYBROOK RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064574777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606858940 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 410 SAYBROOK RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064574777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606858940 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 09/05/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 037659 | CT | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0106X | 037659 | CT | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 207XS0114X | 037659 | CT | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery | 207XS0117X | 037659 | CT | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | 207XX0004X | 037659 | CT | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery | 207XX0005X | 037659 | CT | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207XX0801X | 037659 | CT | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma |
ID Information
| ID | Type | State | Issuer | Description | 001376591 | 05 | CT | MEDICAID |