Provider Demographics
NPI:1245283803
Name:BERCHUCK, MATTHEW (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:BERCHUCK
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 1:3409 WORTH ST
Mailing Address - Street 2:300
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-2029
Mailing Address - Country:US
Mailing Address - Phone:214-865-1350
Mailing Address - Fax:214-865-1351
Practice Address - Street 1:3409 WORTH ST
Practice Address - Street 2:300
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-2029
Practice Address - Country:US
Practice Address - Phone:214-865-1350
Practice Address - Fax:214-865-1351
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP0957207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051531430OtherBLUE CROSS OF ALABAMA
AL009934598Medicaid
TX3125627-02Medicaid
AL009941273Medicaid
AL051531832OtherBLUE CROSS OF ALABAMA
TX3125627-02Medicaid
AL051531430OtherBLUE CROSS OF ALABAMA
AL0506700001Medicare NSC
AL009934598Medicaid