Provider Demographics
NPI:1093703605
Name:BERGGREEN, PAUL J (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:J
Last Name:BERGGREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3020 E CAMELBACK RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-5059
Mailing Address - Country:US
Mailing Address - Phone:602-264-9100
Mailing Address - Fax:602-264-9101
Practice Address - Street 1:1300 N 12TH ST
Practice Address - Street 2:#613
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2848
Practice Address - Country:US
Practice Address - Phone:602-254-5321
Practice Address - Fax:602-254-6582
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2017-02-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ21349207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ131508-03Medicaid
AZ131508Medicaid
AZ317047OtherGROUP MEDICAID NUMBER
AZ120390OtherGROUP MEDICARE NUMBER
AZ317047OtherGROUP MEDICAID NUMBER
10WCHWR05Medicare ID - Type Unspecified
AZ131508-03Medicaid