Provider Demographics
NPI:1407897903
Name:ZOYA BERENSON MD PC-GREATER NE MEDICAL GROUP
Entity Type:Organization
Organization Name:ZOYA BERENSON MD PC-GREATER NE MEDICAL GROUP
Other - Org Name:ZOYA BERENSON MD PC-GREATER NE MEDICAL GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ZOYA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERENSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-464-6104
Mailing Address - Street 1:2000 GRANT AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-4378
Mailing Address - Country:US
Mailing Address - Phone:215-464-6104
Mailing Address - Fax:215-464-9104
Practice Address - Street 1:2000 GRANT AVE STE 201
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-4378
Practice Address - Country:US
Practice Address - Phone:215-464-6104
Practice Address - Fax:215-464-9104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017423170002Medicaid
PA0017423170002Medicaid