Provider Demographics
NPI:1073513982
Name:BERG, JONATHON H (MD)
Entity Type:Individual
Prefix:
First Name:JONATHON
Middle Name:H
Last Name:BERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6002
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201
Mailing Address - Country:US
Mailing Address - Phone:701-780-5000
Mailing Address - Fax:701-587-6009
Practice Address - Street 1:1300 SOUTH COLUMBIA ROAD
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4032
Practice Address - Country:US
Practice Address - Phone:701-780-5000
Practice Address - Fax:701-587-6009
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5113207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN268M0BEOtherMN BCBS
917187OtherFIRST HEALTH (MAILHANDLERS)
01-19160OtherMEDICA
ND12955Medicaid
MN514800600Medicaid
NA9481022061OtherPREFERRED ONE
ND23749OtherND BCBS
MN268M0BEOtherMN BCBS
ND23749Medicare PIN