Provider Demographics
NPI:1811057367
Name:HERMON FAMILY HEALTH CARE
Entity type:Organization
Organization Name:HERMON FAMILY HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:R
Authorized Official - Last Name:BERK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-347-2191
Mailing Address - Street 1:1111 PATTERSON ST
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669-3840
Mailing Address - Country:US
Mailing Address - Phone:315-393-9113
Mailing Address - Fax:
Practice Address - Street 1:105 MAIN ST
Practice Address - Street 2:
Practice Address - City:HERMON
Practice Address - State:NY
Practice Address - Zip Code:13652-3100
Practice Address - Country:US
Practice Address - Phone:315-347-2191
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY158982-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00986576Medicaid
1417059718OtherNPI
=========OtherFED TAX ID
NY00986576Medicaid
1417059718OtherNPI