MEDICARE: BERKELEY MEDICAL ASSOCIATE, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician	123886	NY

General Provider Information

NPI Number	:	1598033177
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BERKELEY MEDICAL ASSOCIATE, PC

Provider Business Mailing Address
First Line	:	PO BOX 270
Second Line	:
City	:	MASSAPEQUA PARK
State	:	NY
Zip	:	11762-0270
Country	:	US
Telephone Number	:	631-264-2035
Fax Number	:	631-264-1418

Provider Business Practice Location Address
First Line	:	207 BERKELEY PL
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11217-3801
Country	:	US
Telephone Number	:	347-529-6322
Fax Number	:	718-638-4033

Authorized Official
Title or Position	:	OWNER
Name	:	JAGDISH K GUPTA
Credential	:	M.D.
Telephone Number	:	917-941-2886

Provider Enumeration Date	:	12/09/2011
Last Update Date	:	12/09/2011

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