Basic Information
| Provider Information | |||||||||
| NPI: | 1942229653 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERMAN | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 68 S SERVICE RD | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117472354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5169453000 | ||||||||
| FaxNumber: | 5169453131 | ||||||||
| Practice Location | |||||||||
| Address1: | 167 E MERRICK RD | ||||||||
| Address2: | |||||||||
| City: | VALLEY STREAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115805925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5168253030 | ||||||||
| FaxNumber: | 5168254282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 11/12/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 200060 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 01908805 | 05 | NY | MEDICAID |