Healthcare Provider Details

I. General information

NPI: 1528055753
Provider Name (Legal Business Name): ROGER L BERKOW MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 JESSE HILL JR DR SE
ATLANTA GA
30303-3032
US

IV. Provider business mailing address

720 WESTVIEW DRIVE SW HARRIS BLDG., 100-A
ATLANTA GA
30310
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-9850
  • Fax:
Mailing address:
  • Phone: 404-756-1400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME117016
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberMD.11429
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberME117016
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number86596
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD.11429
License Number StateAL
# 6
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD.11429
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: