Healthcare Provider Details

I. General information

NPI: 1114274453
Provider Name (Legal Business Name): FRED BERMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2012
Last Update Date: 08/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 SAINT MICHAELS DR
SANTA FE NM
87505-7600
US

IV. Provider business mailing address

1814 PASEO DE LA CONQUISTADORA
SANTA FE NM
87501-2341
US

V. Phone/Fax

Practice location:
  • Phone: 505-438-9402
  • Fax:
Mailing address:
  • Phone: 505-795-8092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA-1214
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: