Provider Demographics
NPI:1598141921
Name:BERSCH, KEITH T (PAC)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:T
Last Name:BERSCH
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 LILLINGTON AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-3189
Mailing Address - Country:US
Mailing Address - Phone:704-362-4403
Mailing Address - Fax:704-362-4405
Practice Address - Street 1:320 LILLINGTON AVE STE 101
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3189
Practice Address - Country:US
Practice Address - Phone:704-362-4403
Practice Address - Fax:704-362-4405
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-07
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52639363A00000X
NC0010-08047363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant