Provider Demographics
NPI:1992850879
Name:STEPHEN C BERENS, MD A MED. CORP.
Entity Type:Organization
Organization Name:STEPHEN C BERENS, MD A MED. CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRE & SEC. OF CORPORATION
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROBERTA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BERENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-828-4633
Mailing Address - Street 1:POB 261037
Mailing Address - Street 2:SUITE 268W
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91426-1037
Mailing Address - Country:US
Mailing Address - Phone:310-828-4633
Mailing Address - Fax:310-828-6205
Practice Address - Street 1:1301 20TH ST.
Practice Address - Street 2:SUITE 590
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404
Practice Address - Country:US
Practice Address - Phone:310-828-4633
Practice Address - Fax:818-784-5639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA22556174400000X
CAA-22556207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1528050408OtherPERSONAL NATIONAL PROVIDE
CAWA22556DMedicare Oscar/Certification
CAWA22556CMedicare ID - Type UnspecifiedOFFICE MEDICARE ID
CA1528050408OtherPERSONAL NATIONAL PROVIDE