Provider Demographics
NPI:1073614145
Name:MAYERBERGER, SCOTT A (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:A
Last Name:MAYERBERGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 E MAIN ST
Mailing Address - Street 2:STE 114
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-3121
Mailing Address - Country:US
Mailing Address - Phone:631-475-7700
Mailing Address - Fax:631-307-9911
Practice Address - Street 1:475 E MAIN ST
Practice Address - Street 2:STE 114
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-3121
Practice Address - Country:US
Practice Address - Phone:631-475-7700
Practice Address - Fax:631-307-9911
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY198877207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01694480Medicaid
NYG07882Medicare UPIN
NY01694480Medicaid