Provider Demographics
NPI:1568444040
Name:BERLIN, KIM J
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:J
Last Name:BERLIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-4098
Mailing Address - Country:US
Mailing Address - Phone:516-623-4580
Mailing Address - Fax:516-623-4588
Practice Address - Street 1:830 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-4098
Practice Address - Country:US
Practice Address - Phone:516-623-4580
Practice Address - Fax:516-623-4588
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN3156213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00490120Medicaid
NY00490120Medicaid
T50964Medicare UPIN