Healthcare Provider Details

I. General information

NPI: 1770554131
Provider Name (Legal Business Name): ANNE B BERCOVITCH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 09/20/2022
Certification Date: 09/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

148 W RIVER ST STE 1B
PROVIDENCE RI
02904-2615
US

IV. Provider business mailing address

526 MAIN ST STE 302
ACTON MA
01720-3301
US

V. Phone/Fax

Practice location:
  • Phone: 401-273-9310
  • Fax: 401-273-1270
Mailing address:
  • Phone: 978-371-7010
  • Fax: 978-371-0522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number38330
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License NumberMD12674
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: