Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | MD60888448 | WA |
Y | 111NI0900X | Internist | MD60888448 | WA |
N | 207RA0401X | Internist - Addiction Medicine | MD60888448 | WA |
NPI | 1427412899 |
---|---|
Provider Name | Dr. Russell David Berg |
First Address | Seattle, WA 98145-5095 |
Second Address | Seattle, WA 98104-2420 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/04/2016 |
Last Update Date | 29/04/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1427412899 | (05) | WA |