Provider Demographics
NPI:1780868166
Name:BERENSON, ERIC J (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:J
Last Name:BERENSON
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:PO BOX 1316
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1316
Mailing Address - Country:US
Mailing Address - Phone:877-440-0479
Mailing Address - Fax:
Practice Address - Street 1:2701 N DECATUR RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-5918
Practice Address - Country:US
Practice Address - Phone:404-564-5400
Practice Address - Fax:404-564-5403
Is Sole Proprietor?:No
Enumeration Date:2007-12-21
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0547912085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA419492424AMedicaid
GA419492424AMedicaid