Provider Demographics
NPI:1184681330
Name:DRS BERGHASH & LANZA PL
Entity Type:Organization
Organization Name:DRS BERGHASH & LANZA PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-979-4035
Mailing Address - Street 1:1801 SE HILLMOOR DR
Mailing Address - Street 2:SUITE B105
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7545
Mailing Address - Country:US
Mailing Address - Phone:772-398-9911
Mailing Address - Fax:772-398-4374
Practice Address - Street 1:1801 SE HILLMOOR DR
Practice Address - Street 2:SUITE B105
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7545
Practice Address - Country:US
Practice Address - Phone:772-398-9911
Practice Address - Fax:772-398-4374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-28
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCH6061OtherRR MEDICARE
FLK2417AMedicare PIN
FLK2417Medicare PIN