Provider Demographics
NPI:1871569830
Name:BEREZOVSKI, ROMAN (MD)
Entity type:Individual
Prefix:DR
First Name:ROMAN
Middle Name:
Last Name:BEREZOVSKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7217 W LAFAYETTE PL
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-1572
Mailing Address - Country:US
Mailing Address - Phone:414-248-8933
Mailing Address - Fax:414-365-0773
Practice Address - Street 1:8901 N 76TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53223-1901
Practice Address - Country:US
Practice Address - Phone:414-354-0772
Practice Address - Fax:414-365-0773
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI48739-202081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34811900Medicaid
WI34811900Medicaid
WI002702870Medicare ID - Type Unspecified