Healthcare Provider Details

I. General information

NPI: 1124019997
Provider Name (Legal Business Name): MICHAEL BRIAN BERES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 08/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 HOSPITAL DR SUITE 400
LOGAN WV
25601-3451
US

IV. Provider business mailing address

PO BOX 116
LOGAN WV
25601-0116
US

V. Phone/Fax

Practice location:
  • Phone: 304-792-1480
  • Fax: 304-792-1481
Mailing address:
  • Phone: 304-792-1480
  • Fax: 304-792-1481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number20176
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: