Basic Information
| Provider Information | |||||||||
| NPI: | 1669433496 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERMAN | ||||||||
| FirstName: | JESSICA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 TROY SCHENECTADY RD STE 203 | ||||||||
| Address2: | |||||||||
| City: | LATHAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121102461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187823700 | ||||||||
| FaxNumber: | 5187823799 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 NEW KARNER RD | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122053874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5183930391 | ||||||||
| FaxNumber: | 5183723281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2006 | ||||||||
| LastUpdateDate: | 02/05/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 226578 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200787 | 01 | NY | SENIOR WHOLE HEALTH | OTHER | 02598630 | 05 | NY | MEDICAID | 116107 | 01 | NY | GHI/HMO | OTHER | 367731 | 01 | NY | MVP | OTHER | 000415821003 | 01 | NY | BSNENY | OTHER | 070606000041 | 01 | NY | FIDELIS | OTHER | 10092905 | 01 | NY | CDPHP | OTHER | 7617595 | 01 | NY | AETNA | OTHER | 5223P1 | 01 | NY | EMPIRE BC | OTHER |