Provider Demographics
NPI:1235187006
Name:BERWICK MEDICAL PROFESSIONALS PC
Entity Type:Organization
Organization Name:BERWICK MEDICAL PROFESSIONALS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VP
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:NEWSOME
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-759-5555
Mailing Address - Street 1:PO BOX 504304
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-0001
Mailing Address - Country:US
Mailing Address - Phone:570-759-5555
Mailing Address - Fax:570-759-5553
Practice Address - Street 1:751 E 16TH ST
Practice Address - Street 2:
Practice Address - City:BERWICK
Practice Address - State:PA
Practice Address - Zip Code:18603-2321
Practice Address - Country:US
Practice Address - Phone:570-759-5555
Practice Address - Fax:570-759-5553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA095753Medicare ID - Type Unspecified