Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Y00000X | Otolaryngologist (ENT Doctor) | EB006059 | MI |
NPI | 1043253339 |
---|---|
Provider Name | Edward D Berg |
First Address | Lansing, MI 48917-1131 |
Second Address | Lansing, MI 48917-1131 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/06/2006 |
Last Update Date | 15/10/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0452329554 | BLUE CROSS BLUE SHIELD (01) | MI |
1063159 | (05) | MI |
200000002582 | PHPMM (01) | MI |
E37538 | (02) |