Provider Demographics
NPI:1124058425
Name:BERKOWITZ, ELLIS R (MD02)
Entity type:Individual
Prefix:DR
First Name:ELLIS
Middle Name:R
Last Name:BERKOWITZ
Suffix:
Gender:M
Credentials:MD02
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5514 CORPORATE DR STE 120
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64507-7754
Mailing Address - Country:US
Mailing Address - Phone:816-271-1350
Mailing Address - Fax:816-271-1355
Practice Address - Street 1:5514 CORPORATE DR STE 120
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64507-7754
Practice Address - Country:US
Practice Address - Phone:816-271-1350
Practice Address - Fax:816-271-1355
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8874207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO110045416OtherRR MEDICARE
KS100312810AMedicaid
MO209319003Medicaid
MO7014947Medicare PIN
MOC51246Medicare UPIN