MEDICARE: DR. BERTRAM OLIVER PLOOG PH.D., BCBA-D

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	103K00000X	Behavior Analyst	000065-1	NY
2	103T00000X	Psychologist	021285	NY

General Provider Information

NPI Number	:	1841426665
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BERTRAM OLIVER PLOOG PH.D., BCBA-D

Provider Business Mailing Address
First Line	:	56 SAINT MARKS PL
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10301-1607
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	56 SAINT MARKS PL
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10301-1607
Country	:	US
Telephone Number	:	718-982-4083
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2009
Last Update Date	:	11/30/2015

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