Provider Demographics
NPI:1952368540
Name:BERCIK, KEVIN J (DO)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:BERCIK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4750 HEMPSTEAD STATION DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5164
Mailing Address - Country:US
Mailing Address - Phone:800-875-0136
Mailing Address - Fax:937-619-4150
Practice Address - Street 1:269 PORTLAND WAY S
Practice Address - Street 2:
Practice Address - City:GALION
Practice Address - State:OH
Practice Address - Zip Code:44833-2312
Practice Address - Country:US
Practice Address - Phone:419-468-4841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34003334B207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000319935OtherBLUE CROSS BLUE SHIELD
OH0528512Medicaid
OHE76374Medicare UPIN
OHP00066458Medicare PIN
OHBE0643068Medicare PIN