Provider Demographics
NPI:1235165523
Name:GARY G. BERGER DO, LLC
Entity Type:Organization
Organization Name:GARY G. BERGER DO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:KEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WASHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-339-9550
Mailing Address - Street 1:5701 W 119TH ST
Mailing Address - Street 2:SUITE 116
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66209-3722
Mailing Address - Country:US
Mailing Address - Phone:913-339-9550
Mailing Address - Fax:
Practice Address - Street 1:5701 W 119TH ST
Practice Address - Street 2:SUITE 116
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66209-3722
Practice Address - Country:US
Practice Address - Phone:913-339-9550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SR0400XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSP170000Medicare ID - Type Unspecified