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General NPI Number Information
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NPI Number | 1508125170
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Entity Type | Organization
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Legal Business Name | KENNETH A. BERDICK, M.D., P.A.
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Dates
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Enumeration Date | 05/16/2012
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Last Update Date | 09/24/2012
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Provider Practice Location Address
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Address Line | 3714 EVANS AVE
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City | FORT MYERS
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State | FL
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Zip | 33901-9303
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Country | US
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Telephone | 239-334-4157
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Fax | 239-334-1904
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Provider Business Mailing Address
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Address Line | 3714 EVANS AVE
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City | FORT MYERS
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State | FL
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Zip | 33901-9303
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Country | US
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Telephone | 239-334-4157
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Fax | 239-334-1904
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Authorized Official
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Title or Position | PRESIDENT
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Name | KENNETH A BERDICK
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Credential | M.D.
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Telephone | 239-334-4157
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0200X
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Taxonomy Name | Pediatric Nurse Practitioner
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License Number | NP1971252
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | ME0017772
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License Number State | FL
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