Provider Demographics
NPI:1245266782
Name:BERENDT, JASON (MD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:BERENDT
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 1:1445 OLD MCDONOUGH HWY SE STE E
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-5977
Mailing Address - Country:US
Mailing Address - Phone:770-922-9222
Mailing Address - Fax:
Practice Address - Street 1:1445 OLD MCDONOUGH HWY SE STE E
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-5977
Practice Address - Country:US
Practice Address - Phone:770-922-9222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23298207R00000X, 208D00000X
GA067390207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC571020809027OtherTRICARE SC
SCP00125604OtherRAILROAD MEDICARE
SC232983Medicaid
SC571020809032OtherBCBS SC
SCP00125604OtherRAILROAD MEDICARE
SCI04157Medicare UPIN
SC232983Medicaid
SC1851342901Medicare PIN
SC1497874424Medicare PIN