1376506022 NPI number — DR. JEFFREY WILLIAM BERG M.D.

Table of content: DR. JEFFREY WILLIAM BERG M.D. (NPI 1376506022)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376506022 NPI number — DR. JEFFREY WILLIAM BERG M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERG
Provider First Name:
JEFFREY
Provider Middle Name:
WILLIAM
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1376506022
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/02/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 909
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40201-0909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-588-0328
Provider Business Mailing Address Fax Number:
502-371-0475

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1169 EASTERN PKWY STE 2211
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40217-1444
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-635-2775
Provider Business Practice Location Address Fax Number:
502-371-0475
Provider Enumeration Date:
04/11/2006

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: 208VP0014X , with the licence number:  22581 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4466067 . This is a "AETNA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 64225816 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000112276 . This is a "BC/BS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 2436583000 . This is a "PASSPORT ADVANATGE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 9237372003 . This is a "CIGNA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 050071439 . This is a "MEDICARE RR" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 164269100 . This is a "DEPT OF LABOR" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 731879 . This is a "FIRST HEALTH WORKMANS COM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: PASSPORT . This is a "PASSPORT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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