Provider Demographics
NPI:1902858855
Name:BERKE, ETHAN MICHAEL (MD, MPH)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:MICHAEL
Last Name:BERKE
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MEDICAL CENTER DR
Mailing Address - Street 2:DHMC - DEPARTMENT OF COMMUNITY AND FAMILY MEDICINE
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03756-1000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18 OLD ETNA RD
Practice Address - Street 2:DHMC - DEPARTMENT OF COMMUNITY AND FAMILY MEDICINE
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03766
Practice Address - Country:US
Practice Address - Phone:603-650-4000
Practice Address - Fax:603-650-4198
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00035349207Q00000X
NH13084207Q00000X
MN63043207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1012802Medicaid
NH30206160Medicaid
G69771Medicare UPIN
VT1012802Medicaid