Basic Information
| Provider Information | |||||||||
| NPI: | 1902974090 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERLIN | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1640 FORT ST | ||||||||
| Address2: | SUITE D ATTN DENISE | ||||||||
| City: | TRENTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481832040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343913057 | ||||||||
| FaxNumber: | 7343913052 | ||||||||
| Practice Location | |||||||||
| Address1: | 23050 WEST ROAD | ||||||||
| Address2: | STE 120 | ||||||||
| City: | BROWNSTOWN TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481831470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346711510 | ||||||||
| FaxNumber: | 7346711570 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 02/21/2017 | ||||||||
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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 | 207R00000X | 5101011297 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | 5101011297 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | 5101011297 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 343818411 | 05 | MI | MEDICAID | 0H27585 | 01 | MI | BLUE CROSS | OTHER |