Provider Demographics
NPI:1679642649
Name:BERGER, MARC JAY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:JAY
Last Name:BERGER
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 1:13726 71ST AVE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-1939
Mailing Address - Country:US
Mailing Address - Phone:212-496-1423
Mailing Address - Fax:
Practice Address - Street 1:13726 71ST AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11367-1939
Practice Address - Country:US
Practice Address - Phone:212-496-1423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY179789207VG0400X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
P695313OtherOXFORD
N28808OtherHEALTHNET NORTHEAST
0005444592OtherAETNA
NY01562156Medicaid
6007240OtherGHI
N28808OtherHEALTHNET NORTHEAST
6007240OtherGHI