Provider Demographics
NPI:1003857137
Name:BERKLEY, ROGER (PT)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:
Last Name:BERKLEY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 PEACHTREE CT
Mailing Address - Street 2:SUITE 105
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-4616
Mailing Address - Country:US
Mailing Address - Phone:631-467-3700
Mailing Address - Fax:
Practice Address - Street 1:20 PEACHTREE CT
Practice Address - Street 2:SUITE 105
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-4616
Practice Address - Country:US
Practice Address - Phone:631-467-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003194225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBA0814Medicare PIN
NYWZWVP1Medicare PIN
NYQL6191Medicare PIN
NYG400023210Medicare PIN
NYG400002011Medicare PIN
NY06528GMedicare PIN
NY07432IMedicare PIN
NYQ7W6U1Medicare PIN