Provider Demographics
NPI:1104858786
Name:BERG, JOLENE KAY (MD)
Entity Type:Individual
Prefix:DR
First Name:JOLENE
Middle Name:KAY
Last Name:BERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:308 DEARBORN COURT
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55343-2000
Mailing Address - Country:US
Mailing Address - Phone:612-718-8984
Mailing Address - Fax:210-426-3787
Practice Address - Street 1:308 DEARBORN COURT
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55343-2000
Practice Address - Country:US
Practice Address - Phone:612-718-8984
Practice Address - Fax:210-426-3787
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26194207Q00000X
TXK1361207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806479600Medicaid
ID806479600Medicaid
A95423Medicare UPIN
MNA95243Medicare UPIN