Healthcare Provider Details

I. General information

NPI: 1649453226
Provider Name (Legal Business Name): BERMING PAN MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2007
Last Update Date: 01/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 OHIO ST
WANATAH IN
46390-0367
US

IV. Provider business mailing address

PO BOX 367
WANATAH IN
46390-0367
US

V. Phone/Fax

Practice location:
  • Phone: 219-733-2755
  • Fax: 219-733-2377
Mailing address:
  • Phone: 219-733-2755
  • Fax: 219-733-2755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CHEN-TSU PAN
Title or Position: MEDICAL DOCTOR
Credential: MD
Phone: 702-486-4255