Provider Demographics
NPI:1255304010
Name:BERKSON, ANDREW R (DO)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:R
Last Name:BERKSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:
Practice Address - Street 1:100 NAVARRE PL STE 6600
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1173
Practice Address - Country:US
Practice Address - Phone:574-647-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002525A208100000X
TXTX TEMP208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300048038Medicaid
INM32727010OtherMEDICARE PTAN
TXBE08S1468OtherBCBS
TX134621OtherCHIPS
TX752616977008OtherTRICARE
TX8S1468OtherBCBS OF TEXAS
TXBE08S1468OtherBCBS
TX176357501Medicaid
TX134621OtherCHIPS