Provider Demographics
NPI:1316072143
Name:GEORGE D. BERTHERMAN,O.D., INC.
Entity type:Organization
Organization Name:GEORGE D. BERTHERMAN,O.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:D
Authorized Official - Last Name:BERTHERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-941-6221
Mailing Address - Street 1:1466 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-2836
Mailing Address - Country:US
Mailing Address - Phone:401-941-6221
Mailing Address - Fax:401-941-6227
Practice Address - Street 1:1466 BROAD ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-2836
Practice Address - Country:US
Practice Address - Phone:401-941-6221
Practice Address - Fax:401-941-6227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1316072Medicaid
RI0308430001Medicare NSC
RI419005464Medicare PIN