Provider Demographics
NPI:1982607388
Name:BERK, STUART (MD)
Entity Type:Individual
Prefix:
First Name:STUART
Middle Name:
Last Name:BERK
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:PO BOX 30731
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33630-3731
Mailing Address - Country:US
Mailing Address - Phone:800-476-8646
Mailing Address - Fax:919-382-3210
Practice Address - Street 1:110 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2828
Practice Address - Country:US
Practice Address - Phone:800-476-8646
Practice Address - Fax:919-382-3210
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME51149207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL05983OtherGROUP # 34457
FL048212900Medicaid
FL05983OtherBCBS FOR GROUP # 45368
FLP00151286Medicare PIN
FL05983OtherGROUP # 34457
FL05983FMedicare ID - Type UnspecifiedGROUP # 34457
FL048212900Medicaid
FL05983EMedicare ID - Type UnspecifiedGROUP #45368