Provider Demographics
NPI:1720220593
Name:BERCHOU, KELLY D (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:D
Last Name:BERCHOU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-1126
Mailing Address - Country:US
Mailing Address - Phone:716-859-2589
Mailing Address - Fax:716-859-2576
Practice Address - Street 1:100 HIGH ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1126
Practice Address - Country:US
Practice Address - Phone:716-859-2589
Practice Address - Fax:716-859-2576
Is Sole Proprietor?:No
Enumeration Date:2009-03-25
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY263321207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03438442Medicaid