Provider Demographics
NPI:1245221647
Name:BERG, MARK A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:BERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 RICE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55103-2148
Mailing Address - Country:US
Mailing Address - Phone:651-227-6551
Mailing Address - Fax:
Practice Address - Street 1:1400 1ST ST NE
Practice Address - Street 2:
Practice Address - City:NEW PRAGUE
Practice Address - State:MN
Practice Address - Zip Code:56071-2215
Practice Address - Country:US
Practice Address - Phone:952-758-2535
Practice Address - Fax:952-548-6160
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN38780207Q00000X, 207QA0000X, 207QG0300X, 207QS0010X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN979826900Medicaid
MNG34358Medicare UPIN
MN080006842Medicare ID - Type Unspecified