Provider Demographics
NPI:1437421435
Name:ANTHONY L BERARDI, PHD PC
Entity Type:Organization
Organization Name:ANTHONY L BERARDI, PHD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:BERARDI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:574-232-1405
Mailing Address - Street 1:300 S SAINT LOUIS BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-3043
Mailing Address - Country:US
Mailing Address - Phone:574-232-1405
Mailing Address - Fax:574-232-0124
Practice Address - Street 1:300 S SAINT LOUIS BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-3043
Practice Address - Country:US
Practice Address - Phone:574-232-1405
Practice Address - Fax:574-232-0124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-07
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20010290A261QM0801X
MI6301006300261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM100064411OtherMEDICARE PTAN
IN201052000 AMedicaid
INM100064411OtherMEDICARE PTAN