Provider Demographics
NPI:1215999347
Name:BEREJAN, BORIS (MD)
Entity type:Individual
Prefix:
First Name:BORIS
Middle Name:
Last Name:BEREJAN
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 1:100 BREWSTER BLVD
Mailing Address - Street 2:NAVAL HOSPITAL
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28547-2538
Mailing Address - Country:US
Mailing Address - Phone:910-450-4159
Mailing Address - Fax:910-450-4194
Practice Address - Street 1:100 BREWSTER BLVD
Practice Address - Street 2:NAVAL HOSPITAL
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28547-2538
Practice Address - Country:US
Practice Address - Phone:910-450-4159
Practice Address - Fax:910-450-4194
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200601041207P00000X
WI38470207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00268123OtherMEDICARE RAILROAD
WI32331700Medicaid
NC5906740Medicaid
NC144KKOtherBCBS
SCQ0104FMedicaid
WIP00229728OtherMEDICARE RAILROAD
WIP00268123OtherMEDICARE RAILROAD
WI32331700Medicaid
NC5906740Medicaid
WIP00229728OtherMEDICARE RAILROAD
WI002445034Medicare PIN