Provider Demographics
NPI:1770568719
Name:BERGER, JACK JICCHAK (MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:JICCHAK
Last Name:BERGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3030 WESTCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:PURCHASE
Mailing Address - State:NY
Mailing Address - Zip Code:10577-2574
Mailing Address - Country:US
Mailing Address - Phone:914-682-6511
Mailing Address - Fax:914-607-6280
Practice Address - Street 1:3030 WESTCHESTER AVE
Practice Address - Street 2:
Practice Address - City:PURCHASE
Practice Address - State:NY
Practice Address - Zip Code:10577-2574
Practice Address - Country:US
Practice Address - Phone:914-682-6511
Practice Address - Fax:914-607-6280
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY132057207RR0500X
CT038356207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWP461OtherOXFORD
NY132057OtherCONNECTICARE
NY133884168OtherEMPIRE STATE PLAN (NYS)
NY00597755Medicaid
NY0D1950/3C1296OtherHEALTH NET
NY133884168OtherMULTIPLAN
NE4540891OtherAETNA NON HMO
NY461517OtherUNITED HEALTH CARE
NY51A531OtherBLUE CROSS PPO
NE133884168OtherBEECH STREET
NY133884168OtherPOMCO
NY000000045882OtherGHI HMO
NY0051090OtherGHI PPO
NY132057-1WOtherWORKERS COMPENSATION
NY132057OtherHIP
NY1721079-005OtherCIGNA
NE2178760OtherAETNA HMO
NY517105OtherPHCS
NY517105OtherPHCS
NY0D1950/3C1296OtherHEALTH NET