Provider Demographics
NPI:1417941006
Name:BERG, SARA A (MD)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:A
Last Name:BERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1623 5TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403
Mailing Address - Country:US
Mailing Address - Phone:509-758-0128
Mailing Address - Fax:509-758-0402
Practice Address - Street 1:1623 5TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403
Practice Address - Country:US
Practice Address - Phone:509-758-0128
Practice Address - Fax:509-758-0402
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-09
Last Update Date:2010-06-29
Deactivation Date:2006-03-25
Deactivation Code:
Reactivation Date:2006-09-13
Provider Licenses
StateLicense IDTaxonomies
WAMD00029192207V00000X
IDM5872207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID58727OtherBLUE CROSS OF IDAHO
152174XXOtherPREFERRED CARE
WA3083164231BERSAOtherMEDICAL SERVICES CORP
WA1067362Medicaid
ID000010004632OtherREGENCE BLUE SHIELD
0005356454OtherAETNA
ID002685500Medicaid
WA2005013110402042OtherPREMERA BLUE CROSS
152174XXOtherPREFERRED CARE
F20969Medicare UPIN
ID58727OtherBLUE CROSS OF IDAHO
0005356454OtherAETNA