Provider Demographics
NPI:1942486071
Name:BERG, JEROME D (BS REG PH)
Entity Type:Individual
Prefix:MR
First Name:JEROME
Middle Name:D
Last Name:BERG
Suffix:
Gender:M
Credentials:BS REG PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GARET PLACE
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725
Mailing Address - Country:US
Mailing Address - Phone:631-864-0828
Mailing Address - Fax:631-864-0874
Practice Address - Street 1:1 GARET PLACE
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725
Practice Address - Country:US
Practice Address - Phone:631-864-0828
Practice Address - Fax:631-864-0874
Is Sole Proprietor?:No
Enumeration Date:2008-01-18
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025712183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist