Provider Demographics
NPI:1396101044
Name:BERCOVICH, SAM J
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:J
Last Name:BERCOVICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 DRAPER LN
Mailing Address - Street 2:APT 1GS
Mailing Address - City:DOBBS FERRY
Mailing Address - State:NY
Mailing Address - Zip Code:10522-1011
Mailing Address - Country:US
Mailing Address - Phone:718-344-8092
Mailing Address - Fax:
Practice Address - Street 1:110 DRAPER LN
Practice Address - Street 2:APT 1GS
Practice Address - City:DOBBS FERRY
Practice Address - State:NY
Practice Address - Zip Code:10522-1011
Practice Address - Country:US
Practice Address - Phone:718-344-8092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-11
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1329084174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist