Provider Demographics
NPI:1316082399
Name:BERKLEY PRIMARY CARE, PLC
Entity type:Organization
Organization Name:BERKLEY PRIMARY CARE, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:S
Authorized Official - Last Name:VACHERESSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-543-6000
Mailing Address - Street 1:26711 WOODWARD AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48070-1367
Mailing Address - Country:US
Mailing Address - Phone:248-543-6000
Mailing Address - Fax:248-543-3770
Practice Address - Street 1:26711 WOODWARD AVE STE 103
Practice Address - Street 2:
Practice Address - City:HUNTINGTON WOODS
Practice Address - State:MI
Practice Address - Zip Code:48070-1367
Practice Address - Country:US
Practice Address - Phone:248-543-6000
Practice Address - Fax:248-543-3770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI208000000X
207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N56290Medicare ID - Type Unspecified