Provider Demographics
NPI:1205925682
Name:SODERBERG, BECK (MD)
Entity type:Individual
Prefix:DR
First Name:BECK
Middle Name:
Last Name:SODERBERG
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 1:139 BERKELEY RD
Mailing Address - Street 2:
Mailing Address - City:DEVON
Mailing Address - State:PA
Mailing Address - Zip Code:19333-1544
Mailing Address - Country:US
Mailing Address - Phone:610-687-0715
Mailing Address - Fax:610-964-1228
Practice Address - Street 1:139 BERKELEY RD
Practice Address - Street 2:
Practice Address - City:DEVON
Practice Address - State:PA
Practice Address - Zip Code:19333-1544
Practice Address - Country:US
Practice Address - Phone:610-687-0715
Practice Address - Fax:610-964-1228
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD066886L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA800558OtherMEDICARE ID TYPE UNSPECIFIED
PA800558OtherMEDICARE ID TYPE UNSPECIFIED
PAH28468Medicare UPIN