=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104185289
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STANLEY J BERKE MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2012
-----------------------------------------------------
Last Update Date | 06/28/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 901 STEWART AVE SUITE 255
-----------------------------------------------------
City | GARDEN CITY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11530-4893
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-794-2020
-----------------------------------------------------
Fax | 516-794-2029
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1600 STEWART AVE SUITE 306
-----------------------------------------------------
City | WESTBURY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11590-6696
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-794-2020
-----------------------------------------------------
Fax | 516-794-2029
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | DR. STANLEY J BERKE
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 516-794-2020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 151730
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------