Provider Demographics
NPI:1427195809
Name:MYRTLE RIDGE FAMILY MEDICINE, PA
Entity Type:Organization
Organization Name:MYRTLE RIDGE FAMILY MEDICINE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-909-7102
Mailing Address - Street 1:PO BOX 660
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33548-0660
Mailing Address - Country:US
Mailing Address - Phone:813-909-7102
Mailing Address - Fax:813-909-0199
Practice Address - Street 1:1539 DALE MABRY HWY
Practice Address - Street 2:102
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33548-3008
Practice Address - Country:US
Practice Address - Phone:813-909-7102
Practice Address - Fax:813-909-0199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0056971207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL770008300Medicaid
E91794Medicare UPIN
FL770008300Medicaid