Basic Information
| Provider Information | |||||||||
| NPI: | 1427057728 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERKSON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 530 PARK AVE E | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8158752811 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 530 PARK AVE E STE 306 | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 613563903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8158763099 | ||||||||
| FaxNumber: | 8158763003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2005 | ||||||||
| LastUpdateDate: | 12/09/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 036-052590 | IL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 036052590 | 05 | IL | MEDICAID | 0451517835 | 01 | BLUE SHIELD | OTHER | 791203314 | 01 | RR MEDICARE | OTHER | 200008160 | 01 | RR MEDICARE | OTHER |