Provider Demographics
NPI:1295817336
Name:BERGH, BRYAN JOHN (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:JOHN
Last Name:BERGH
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 1:525 PORTLAND AVE
Mailing Address - Street 2:HSB MC 952
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55415-1533
Mailing Address - Country:US
Mailing Address - Phone:612-348-9840
Mailing Address - Fax:612-596-7900
Practice Address - Street 1:1801 NICOLLET AVE.
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403
Practice Address - Country:US
Practice Address - Phone:612-348-9840
Practice Address - Fax:612-596-7900
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN323742084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN753273300Medicaid
MN753273300Medicaid
MN260002439Medicare ID - Type Unspecified