Basic Information
| Provider Information | |||||||||
| NPI: | 1821047283 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERMAN | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 YORK ST | ||||||||
| Address2: | |||||||||
| City: | MANITOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542204630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9206639008 | ||||||||
| FaxNumber: | 9206841439 | ||||||||
| Practice Location | |||||||||
| Address1: | 7040 N PORT WASHINGTON RD | ||||||||
| Address2: | SUITE 404 | ||||||||
| City: | GLENDALE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532173885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143552405 | ||||||||
| FaxNumber: | 4143556460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 10/12/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0101X | 27925 | WI | N | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery | 207NP0225X | 27925 | WI | N | Allopathic & Osteopathic Physicians | Dermatology | Pediatric Dermatology | 207NS0135X | 27925 | WI | N | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology | 207N00000X | 27925 | WI | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 52DO946226 | 01 | WI | CLIA | OTHER | 31392100 | 05 | WI | MEDICAID | 391130058 | 01 | WI | TAX ID# | OTHER |