Provider Demographics
NPI:1649672585
Name:BERGER, JEREMY J (RPA-C)
Entity type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:J
Last Name:BERGER
Suffix:
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 S BEDFORD RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT KISCO
Mailing Address - State:NY
Mailing Address - Zip Code:10549-3446
Mailing Address - Country:US
Mailing Address - Phone:914-241-1050
Mailing Address - Fax:
Practice Address - Street 1:1978 CROMPOND RD
Practice Address - Street 2:
Practice Address - City:CORTLANDT MANOR
Practice Address - State:NY
Practice Address - Zip Code:10567-4111
Practice Address - Country:US
Practice Address - Phone:914-241-1050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-23
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017988363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04542421Medicaid