1891857058 NPI number — MS. BRIDGET LYNN BERG

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 1891857058 NPI number — MS. BRIDGET LYNN BERG

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERG
Provider First Name:
BRIDGET
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1891857058
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/07/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1018 BANBURY CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NAPA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94558-4354
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-255-5139
Provider Business Mailing Address Fax Number:
707-255-5139

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2101 COURAGE DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRFIELD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-784-4900
Provider Business Practice Location Address Fax Number:
707-399-4957
Provider Enumeration Date:
12/14/2006

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: 101YM0800X , with the licence number:  IMF98165 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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