Provider Demographics
NPI:1669520235
Name:BERAN, JEFFREY JOSEPH (PT)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:JOSEPH
Last Name:BERAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15953 N GREENWAY HAYDEN LOOP STE A
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-1765
Mailing Address - Country:US
Mailing Address - Phone:480-767-2769
Mailing Address - Fax:480-361-9734
Practice Address - Street 1:15953 N GREENWAY HAYDEN LOOP STE A
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-1765
Practice Address - Country:US
Practice Address - Phone:480-767-2769
Practice Address - Fax:480-361-9734
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7398225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1669520235OtherNIP
AZAZ0461720OtherGROUP NUMBER
AZ2Z8898OtherHEALTH NET NUMBER
AZ454198977OtherTAX ID
AZ610640800OtherGROUP OWCP NUMBER
AZ2Z8898OtherHEALTH NET NUMBER