=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114196284
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEVEN BERKOV MD, PHD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2008
-----------------------------------------------------
Last Update Date | 02/22/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1872 INDIAN VALLEY RD
-----------------------------------------------------
City | NOVATO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94947-4225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-893-9575
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1872 INDIAN VALLEY RD
-----------------------------------------------------
City | NOVATO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94947-4225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-893-9575
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number | G33248
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------