Provider Demographics
NPI:1972010726
Name:BERK, SCOTTIE DANIELLE
Entity Type:Individual
Prefix:MS
First Name:SCOTTIE
Middle Name:DANIELLE
Last Name:BERK
Suffix:
Gender:F
Credentials:
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 37086
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3086
Mailing Address - Country:US
Mailing Address - Phone:240-439-8812
Mailing Address - Fax:
Practice Address - Street 1:1562 OPOSSUMTOWN PIKE
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4920
Practice Address - Country:US
Practice Address - Phone:240-215-6310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-02
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC06680363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant