Provider Demographics
NPI:1710927561
Name:BEBERMAN-JENNES, PHILLIS (DO)
Entity Type:Individual
Prefix:
First Name:PHILLIS
Middle Name:
Last Name:BEBERMAN-JENNES
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4920 MAIN ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-1300
Mailing Address - Country:US
Mailing Address - Phone:203-374-1515
Mailing Address - Fax:203-374-4702
Practice Address - Street 1:4920 MAIN ST
Practice Address - Street 2:SUITE 202
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606
Practice Address - Country:US
Practice Address - Phone:203-374-1515
Practice Address - Fax:203-374-4702
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000424207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
113568598OtherTRICARE
NY0088T1OtherEMPIRE BC
CT001004241Medicaid
CT050001474Medicare ID - Type Unspecified
113568598OtherTRICARE