Provider Demographics
NPI:1285697201
Name:BERGER, GLEN W (MD)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:W
Last Name:BERGER
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 1:110 WARREN AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:HO HO KUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07423-1566
Mailing Address - Country:US
Mailing Address - Phone:201-444-9405
Mailing Address - Fax:201-444-9408
Practice Address - Street 1:110 WARREN AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:HO HO KUS
Practice Address - State:NJ
Practice Address - Zip Code:07423-1566
Practice Address - Country:US
Practice Address - Phone:201-444-9405
Practice Address - Fax:201-444-9408
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2012-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06271300207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJF36282Medicare UPIN
NJ800456Medicare ID - Type Unspecified