Provider Demographics
NPI:1699889337
Name:BERMAN, BRUCE LEE (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:LEE
Last Name:BERMAN
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 1:2791 RICHMOND AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-5859
Mailing Address - Country:US
Mailing Address - Phone:718-816-6440
Mailing Address - Fax:
Practice Address - Street 1:1050 CLOVE RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-3627
Practice Address - Country:US
Practice Address - Phone:718-816-6440
Practice Address - Fax:718-816-3749
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2012-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY185296-1207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01504489Medicaid
NY20J221Medicare ID - Type Unspecified
NY01504489Medicaid