1457309767 NPI number — DR. DAVID DOUGLAS BERG D.O.

Table of content: DR. DAVID DOUGLAS BERG D.O. (NPI 1457309767)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457309767 NPI number — DR. DAVID DOUGLAS BERG D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERG
Provider First Name:
DAVID
Provider Middle Name:
DOUGLAS
Provider Name Prefix Text:
DR.
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:
1457309767
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/04/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2184
Provider Second Line Business Mailing Address:
CERTIFIED EMERGENCY MEDICINE SPECIALISTS, PC
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49501-2184
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-363-7867
Provider Business Mailing Address Fax Number:
616-363-9432

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5900 BYRON CENTER SW
Provider Second Line Business Practice Location Address:
METRO HEALTH HOSPITAL
Provider Business Practice Location Address City Name:
WYOMING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49519
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-252-7123
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/05/2006

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: 207P00000X , with the licence number:  5101013441 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4413279 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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