=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316082399
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BERKLEY PRIMARY CARE, PLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2007
-----------------------------------------------------
Last Update Date | 02/03/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 26711 WOODWARD AVE STE 103
-----------------------------------------------------
City | HUNTINGTON WOODS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48070-1367
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-543-6000
-----------------------------------------------------
Fax | 248-543-3770
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26711 WOODWARD AVE STE 103
-----------------------------------------------------
City | HUNTINGTON WOODS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48070-1367
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-543-6000
-----------------------------------------------------
Fax | 248-543-3770
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MS. TERRY S VACHERESSE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 248-543-6000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------