Provider Demographics
NPI:1376637421
Name:BERG, TRACY A (MD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:A
Last Name:BERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:A
Other - Last Name:MAGNUSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:16201 E INDIANA AVE
Mailing Address - Street 2:STE 3100
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99216-2830
Mailing Address - Country:US
Mailing Address - Phone:509-891-8904
Mailing Address - Fax:509-344-3104
Practice Address - Street 1:16201 E INDIANA AVE
Practice Address - Street 2:STE 3100
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-2830
Practice Address - Country:US
Practice Address - Phone:509-891-8904
Practice Address - Fax:509-344-3104
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000326152086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1123884Medicaid
WAG10477Medicare UPIN
WAG8865131Medicare PIN