Healthcare Provider Details

I. General information

NPI: 1073868972
Provider Name (Legal Business Name): MARLYSE BERGER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2012
Last Update Date: 01/10/2023
Certification Date: 01/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 E 68TH ST
NEW YORK NY
10065-4870
US

IV. Provider business mailing address

200 E 71ST ST APT 4G
NEW YORK NY
10021-0462
US

V. Phone/Fax

Practice location:
  • Phone: 212-746-3400
  • Fax:
Mailing address:
  • Phone: 860-833-4462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: