Provider Demographics
NPI:1134401474
Name:PORT WASHINGTON GASTROENTEROLOGY, PC
Entity type:Organization
Organization Name:PORT WASHINGTON GASTROENTEROLOGY, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:S
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-684-9229
Mailing Address - Street 1:2001 MARCUS AVE
Mailing Address - Street 2:SUITE N204
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-2061
Mailing Address - Country:US
Mailing Address - Phone:516-684-9229
Mailing Address - Fax:516-684-9918
Practice Address - Street 1:2001 MARCUS AVE
Practice Address - Street 2:SUITE N204
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-2061
Practice Address - Country:US
Practice Address - Phone:516-684-9229
Practice Address - Fax:516-684-9918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-13
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY198682174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA100058956Medicare UPIN