1750704797 NPI number — AMANDA M BERGER CRNA

Table of content: AMANDA M BERGER CRNA (NPI 1750704797)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750704797 NPI number — AMANDA M BERGER CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERGER
Provider First Name:
AMANDA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ELLIOTT
Provider Other First Name:
AMANDA
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1750704797
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
68 S SERVICE RD
Provider Second Line Business Mailing Address:
SUITE 350
Provider Business Mailing Address City Name:
MELVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11747-2354
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-945-3000
Provider Business Mailing Address Fax Number:
302-733-0854

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
350 N WALL ST
Provider Second Line Business Practice Location Address:
DEPT OF ANESTHESIA
Provider Business Practice Location Address City Name:
KANKAKEE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60901-2901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-933-1671
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/28/2014

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: 163W00000X , with the licence number:  041.368295 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 209.011212 , 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)

  • Identifier: 93260 . This is a "AANA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".