Provider Demographics
NPI:1154510964
Name:BERGER, ILYSE G (RD)
Entity Type:Individual
Prefix:
First Name:ILYSE
Middle Name:G
Last Name:BERGER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:DENVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07834-2153
Mailing Address - Country:US
Mailing Address - Phone:973-519-9167
Mailing Address - Fax:
Practice Address - Street 1:400 WEST BLACKWELL STREET
Practice Address - Street 2:SAINT CLARE'S HOSPITAL
Practice Address - City:DOVER
Practice Address - State:NJ
Practice Address - Zip Code:07801
Practice Address - Country:US
Practice Address - Phone:973-989-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ00981040133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered