Provider Demographics
NPI:1104239797
Name:BERLACHER, MARK (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BERLACHER
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 1:541 CLINICAL DRIVE, CL 626
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202
Mailing Address - Country:US
Mailing Address - Phone:800-362-2066
Mailing Address - Fax:
Practice Address - Street 1:1955 DIXIE HWY STE E
Practice Address - Street 2:
Practice Address - City:FT WRIGHT
Practice Address - State:KY
Practice Address - Zip Code:41011-2882
Practice Address - Country:US
Practice Address - Phone:859-292-4560
Practice Address - Fax:859-292-4561
Is Sole Proprietor?:No
Enumeration Date:2014-06-11
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35141460207RC0000X
IN11017791A390200000X
KY55150207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0440583Medicaid