Provider Demographics
NPI:1982039129
Name:COSTA BERKSHIRE GROUP LLC
Entity Type:Organization
Organization Name:COSTA BERKSHIRE GROUP LLC
Other - Org Name:DOUGLAS BAILYN MBR
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-777-1510
Mailing Address - Street 1:111 BROADWAY
Mailing Address - Street 2:SUITE 1302
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10006-1901
Mailing Address - Country:US
Mailing Address - Phone:212-777-1510
Mailing Address - Fax:
Practice Address - Street 1:111 BROADWAY
Practice Address - Street 2:SUITE 1302
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10006-1901
Practice Address - Country:US
Practice Address - Phone:212-777-1510
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-06
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty