1992773691 NPI number — LISBETH K BERGE MD

Table of content: LISBETH K BERGE MD (NPI 1992773691)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992773691 NPI number — LISBETH K BERGE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERGE
Provider First Name:
LISBETH
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1992773691
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/09/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3801 UNIVERSITY LAKE DR STE 301
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANCHORAGE
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99508-4658
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-777-1850
Provider Business Mailing Address Fax Number:
855-468-1357

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3801 UNIVERSITY WAY DR.
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
ANCHORAGE
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-777-1850
Provider Business Practice Location Address Fax Number:
907-777-1800
Provider Enumeration Date:
03/09/2006

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: 207Q00000X , with the licence number:  3927 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X , with the licence number: 3927 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 152556 . This is a "MCARE" identifier , issued by the state of ( AK ) . This identifiers is of the category "OTHER".
  • Identifier: MD03282 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3927 . This is a "AK STATE MEDICAL LICENSE" identifier , issued by the state of ( AK ) . This identifiers is of the category "OTHER".




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