Healthcare Provider Details

I. General information

NPI: 1619345436
Provider Name (Legal Business Name): BERKS DIABETES MANAGEMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2015
Last Update Date: 09/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 REED AVE SUITE 116
WYOMISSING PA
19610-2039
US

IV. Provider business mailing address

1030 REED AVE SUITE 116
WYOMISSING PA
19610-2039
US

V. Phone/Fax

Practice location:
  • Phone: 610-373-7743
  • Fax: 610-378-9337
Mailing address:
  • Phone: 610-373-7743
  • Fax: 610-378-9337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberSP007277
License Number StatePA

VIII. Authorized Official

Name: MR. RALPH MICHAEL CINCINNATI
Title or Position: NURSE PRACTITIONER
Credential: CRNP
Phone: 610-927-9815