Healthcare Provider Details

I. General information

NPI: 1104239797
Provider Name (Legal Business Name): MARK BERLACHER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2014
Last Update Date: 08/16/2021
Certification Date: 08/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1955 DIXIE HWY STE E
FT WRIGHT KY
41011-2882
US

IV. Provider business mailing address

541 CLINICAL DRIVE, CL 626
INDIANAPOLIS IN
46202
US

V. Phone/Fax

Practice location:
  • Phone: 859-292-4560
  • Fax: 859-292-4561
Mailing address:
  • Phone: 800-362-2066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number11017791A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number35141460
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number55150
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: