Basic Information
| Provider Information | |||||||||
| NPI: | 1962473314 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERCOVITCH | ||||||||
| FirstName: | LIONEL | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 593 EDDY STREET, | ||||||||
| Address2: | APC-10 | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 02903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014447959 | ||||||||
| FaxNumber: | 4014447144 | ||||||||
| Practice Location | |||||||||
| Address1: | 593 EDDY STREET, | ||||||||
| Address2: | APC-10 | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 02903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014447959 | ||||||||
| FaxNumber: | 4014447144 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2006 | ||||||||
| LastUpdateDate: | 08/21/2013 | ||||||||
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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 | 207NI0002X | 36392 | MA | N | Allopathic & Osteopathic Physicians | Dermatology | Clinical & Laboratory Dermatological Immunology | 207N00000X | MD05283 | RI | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.