Provider Demographics
NPI:1740268655
Name:BERLIN, BURGESS L (MD)
Entity type:Individual
Prefix:
First Name:BURGESS
Middle Name:L
Last Name:BERLIN
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 1:125 PROSPECT STREET
Mailing Address - Street 2:
Mailing Address - City:SOUTH ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07079
Mailing Address - Country:US
Mailing Address - Phone:973-761-7755
Mailing Address - Fax:973-761-6290
Practice Address - Street 1:125 PROSPECT STREET
Practice Address - Street 2:
Practice Address - City:SOUTH ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07079
Practice Address - Country:US
Practice Address - Phone:973-761-7755
Practice Address - Fax:973-761-6290
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-03
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25 MA 0306 5300207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
046172OtherMEDICARE
NJ3024601Medicaid
BE 429726Medicare ID - Type Unspecified
NJ3024601Medicaid