1770634560 NPI number — BARRY W BERGER D.O.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770634560 NPI number — BARRY W BERGER D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERGER
Provider First Name:
BARRY
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770634560
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/09/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4626 N BORGATELLO LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85018-3002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-661-4800
Provider Business Mailing Address Fax Number:
602-368-9002

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
290 N RAND RD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
LAKE ZURICH
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60047-2213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-438-2454
Provider Business Practice Location Address Fax Number:
847-438-2462
Provider Enumeration Date:
01/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  036062693 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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