MEDICARE: WALLACE P BERKOWITZ MD LTD

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	207Y00000X	Otolaryngology Physician	R4234	MO
2	207Y00000X	Otolaryngology Physician		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	100287	OTHER		HEALTHPARTNERS
2	M2229	OTHER	MO	MO MCR SUBMITTER ID
3	08200436	OTHER	IL	BCBS OF IL
4	2230168	OTHER		AETNA HMO
5	4376271	OTHER		AETNA PPO
6	6670	OTHER		BLUE CHOICE
7	6670	OTHER	MO	ALLIANCE ALL CHOICE BASIC
8	R4234	OTHER	MO	MO LICENSE NUMBER
9	1007077	OTHER		UHC
10	119451	OTHER		HEALTHLINK

General Provider Information

NPI Number	:	1952387516
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WALLACE P BERKOWITZ MD LTD

Provider Business Mailing Address
First Line	:	6651 CHIPPEWA
Second Line	:	STE 324
City	:	ST LOUIS
State	:	MO
Zip	:	63109-2538
Country	:	US
Telephone Number	:	314-647-8895
Fax Number	:	314-647-8898

Provider Business Practice Location Address
First Line	:	6651 CHIPPEWA
Second Line	:	STE 324
City	:	ST LOUIS
State	:	MO
Zip	:	63109-2538
Country	:	US
Telephone Number	:	314-647-8895
Fax Number	:	314-647-8898

Authorized Official
Title or Position	:	PRESIDENT OWNER
Name	:	WALLACE P BERKOWITZ
Credential	:	MD
Telephone Number	:	314-647-8895

Provider Enumeration Date	:	12/15/2005
Last Update Date	:	04/20/2008

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