Basic Information
| Provider Information | |||||||||
| NPI: | 1619328127 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERLIN | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | JON | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 DUDLEY ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029053236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014571500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2 DUDLEY ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029053236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014571500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2016 | ||||||||
| LastUpdateDate: | 07/05/2016 | ||||||||
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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 | 363A00000X | PA00895 | RI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.