Provider Demographics
NPI:1235201237
Name:DVORAK BERGER, REBECCA (RN)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:
Last Name:DVORAK BERGER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 13TH AVE W STE 1
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-4875
Mailing Address - Country:US
Mailing Address - Phone:701-227-7589
Mailing Address - Fax:701-227-7575
Practice Address - Street 1:300 13TH AVE W STE 1
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-4875
Practice Address - Country:US
Practice Address - Phone:701-227-7589
Practice Address - Fax:701-227-7575
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR27811163W00000X
NDTECH1115183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND54523Medicaid