Provider Demographics
NPI:1750349569
Name:BERUMEN, MIKE (MD)
Entity type:Individual
Prefix:DR
First Name:MIKE
Middle Name:
Last Name:BERUMEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MIGUEL
Other - Middle Name:
Other - Last Name:BERUMEN
Other - Suffix:III
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2713 S 74TH ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-5170
Mailing Address - Country:US
Mailing Address - Phone:479-484-7100
Mailing Address - Fax:479-478-7255
Practice Address - Street 1:2713 S 74TH ST
Practice Address - Street 2:SUITE 301
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-5170
Practice Address - Country:US
Practice Address - Phone:479-484-7100
Practice Address - Fax:479-478-7255
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR3019207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARD04359Medicare UPIN
AR50461B329Medicare ID - Type Unspecified