=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952387516
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WALLACE P BERKOWITZ MD LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2005
-----------------------------------------------------
Last Update Date | 04/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6651 CHIPPEWA STE 324
-----------------------------------------------------
City | ST LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63109-2538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-647-8895
-----------------------------------------------------
Fax | 314-647-8898
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6651 CHIPPEWA STE 324
-----------------------------------------------------
City | ST LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63109-2538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-647-8895
-----------------------------------------------------
Fax | 314-647-8898
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT OWNER
-----------------------------------------------------
Name | WALLACE P BERKOWITZ
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 314-647-8895
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number | R4234
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------