Provider Demographics
NPI:1003802588
Name:BERGH, MARY E (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:BERGH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:E
Other - Last Name:DONOGHUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:755 WALTHER RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-8725
Mailing Address - Country:US
Mailing Address - Phone:770-252-0399
Mailing Address - Fax:770-822-5389
Practice Address - Street 1:980 JOHNSON FERRY RD STE 520
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1637
Practice Address - Country:US
Practice Address - Phone:404-303-3320
Practice Address - Fax:404-303-3464
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA41726207RC0000X, 207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00685176AMedicaid
G28422Medicare UPIN
GA06BDFJFMedicare ID - Type Unspecified