Provider Demographics
NPI:1457571499
Name:BERENT, PHILIP GEORGE (DC)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:GEORGE
Last Name:BERENT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3850 MCKINLEY ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-3674
Mailing Address - Country:US
Mailing Address - Phone:313-562-4919
Mailing Address - Fax:
Practice Address - Street 1:125 SAINT MARY DR
Practice Address - Street 2:
Practice Address - City:PORT SANILAC
Practice Address - State:MI
Practice Address - Zip Code:48469-9656
Practice Address - Country:US
Practice Address - Phone:810-622-8202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301004763111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI11271830Other(CAQH)
MI950G6511OtherBLUE CROSS BLUE SHIELD
MI0G65111Medicare ID - Type Unspecified