Basic Information
Provider Information | |||||||||
NPI: | 1992898563 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BERKOVICH | ||||||||
FirstName: | BETSY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7B JOHNSON RD | ||||||||
Address2: |   | ||||||||
City: | LATHAM | ||||||||
State: | NY | ||||||||
PostalCode: | 121103003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5187827733 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 7B JOHNSON RD | ||||||||
Address2: |   | ||||||||
City: | LATHAM | ||||||||
State: | NY | ||||||||
PostalCode: | 121103003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5187827733 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/02/2006 | ||||||||
LastUpdateDate: | 03/18/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0006X | 275895 | NY | Y |   | Allopathic & Osteopathic Physicians | Pediatrics | Developmental – Behavioral Pediatrics | 208000000X | 275895 | NY | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 456ZM1 | 01 | NY | EMPIRE BLUECROOS BLUESHIELD | OTHER | 9783416 | 01 | NY | AETNA | OTHER | 03932881 | 05 | NY |   | MEDICAID | 485103 | 05 | AZ |   | MEDICAID | 8HBU69 | 01 | AZ | MEDICARE PART B - PARKER | OTHER |