Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 38780 | MN |
N | 207QG0300X | Family Doctor - Geriatric Medicine | 38780 | MN |
N | 207QS0010X | Family Doctor - Sports Medicine | 38780 | MN |
N | 207V00000X | Obstetrician & Gynecologist | 38780 | MN |
NPI | 1245221647 |
---|---|
Provider Name | Dr. Mark A Berg |
First Address | Saint Paul, MN 55103-2148 |
Second Address | New Prague, MN 56071-2215 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/11/2005 |
Last Update Date | 30/08/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
979826900 | (05) | MN |
G34358 | (02) | MN |