Provider Demographics
NPI:1962473314
Name:BERCOVITCH, LIONEL G (MD)
Entity Type:Individual
Prefix:
First Name:LIONEL
Middle Name:G
Last Name:BERCOVITCH
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 1:593 EDDY STREET,
Mailing Address - Street 2:APC-10
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903
Mailing Address - Country:US
Mailing Address - Phone:401-444-7959
Mailing Address - Fax:401-444-7144
Practice Address - Street 1:593 EDDY STREET,
Practice Address - Street 2:APC-10
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903
Practice Address - Country:US
Practice Address - Phone:401-444-7959
Practice Address - Fax:401-444-7144
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA36392207NI0002X
RIMD05283207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAA29623Medicare UPIN
A29623Medicare UPIN
MAA02074Medicare PIN