Provider Demographics
NPI:1215999115
Name:BERDY, JACK M (MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:M
Last Name:BERDY
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 1:155 CEDAR LN
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-4301
Mailing Address - Country:US
Mailing Address - Phone:201-836-4248
Mailing Address - Fax:201-836-5420
Practice Address - Street 1:155 CEDAR LN
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-4301
Practice Address - Country:US
Practice Address - Phone:201-836-4248
Practice Address - Fax:201-836-5420
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA60816207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0853523000OtherAMERIHEALTH#
NJP00332714OtherRAILROAD MEDICARE #
NJ0125870OtherGHI PPO#
NJ3K3825OtherHEALTHNET#
NJ0479230OtherAETNA HMO #
NJ230SB2OtherEMPIRE BC/BS #
NJ6925201Medicaid
NJP3688668OtherOXFORD #
NY0479230OtherAETNA PPO#
NJ822513PWSMedicare PIN
NJ3K3825OtherHEALTHNET#