Provider Demographics
NPI:1053362970
Name:BERGER, MITCHELL RUSS (MD)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:RUSS
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 1:1999 MARCUS AVE
Mailing Address - Street 2:SUITE M14
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1023
Mailing Address - Country:US
Mailing Address - Phone:516-437-4360
Mailing Address - Fax:
Practice Address - Street 1:1999 MARCUS AVE
Practice Address - Street 2:SUITE M14
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1023
Practice Address - Country:US
Practice Address - Phone:516-437-4360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY173108207R00000X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYE85638Medicare UPIN
NY82F681Medicare ID - Type Unspecified