Basic Information
| Provider Information | |||||||||
| NPI: | 1356318018 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERDE | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 LONGWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021155724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6173556000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 LONGWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021155724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6173556995 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2006 | ||||||||
| LastUpdateDate: | 08/20/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 54097 | MA | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 2080P0203X | 54097 | MA | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 6194109 | 05 | MA | MEDICAID |