Healthcare Provider Details

I. General information

NPI: 1821425067
Provider Name (Legal Business Name): ANDREW ELLIOT BERDY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2013
Last Update Date: 07/06/2022
Certification Date: 07/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 MEMORIAL DR STE W1
BELLEVILLE IL
62226-5359
US

IV. Provider business mailing address

4600 MEMORIAL DR STE W1
BELLEVILLE IL
62226-5359
US

V. Phone/Fax

Practice location:
  • Phone: 618-233-3066
  • Fax: 618-233-3180
Mailing address:
  • Phone: 618-233-3066
  • Fax: 618-233-3180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number036160345
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036160345
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: