Provider Demographics
NPI:1588636625
Name:BERZON, ELLIS JAY (MD)
Entity type:Individual
Prefix:DR
First Name:ELLIS
Middle Name:JAY
Last Name:BERZON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4485 WILLIAM FLYNN HWY
Mailing Address - Street 2:
Mailing Address - City:ALLISON PARK
Mailing Address - State:PA
Mailing Address - Zip Code:15101-1424
Mailing Address - Country:US
Mailing Address - Phone:412-492-0800
Mailing Address - Fax:412-492-4057
Practice Address - Street 1:4485 WILLIAM FLYNN HWY
Practice Address - Street 2:
Practice Address - City:ALLISON PARK
Practice Address - State:PA
Practice Address - Zip Code:15101-1424
Practice Address - Country:US
Practice Address - Phone:412-492-0800
Practice Address - Fax:412-492-4057
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD056238L174400000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018097570005Medicaid
PA0018097570005Medicaid
PA043878PDHMedicare PIN