Provider Demographics
NPI:1467497610
Name:BERGH, KENT DAVIS (MD)
Entity Type:Individual
Prefix:DR
First Name:KENT
Middle Name:DAVIS
Last Name:BERGH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3100 KENNARD ST
Mailing Address - Street 2:SUITE 100 HEALTHEAST MAPLEWOOD CLINIC,
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109
Mailing Address - Country:US
Mailing Address - Phone:651-232-7800
Mailing Address - Fax:
Practice Address - Street 1:3100 KENNARD ST
Practice Address - Street 2:SUITE 100 HEALTHEAST PHYSICIAN SERVICE,
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109
Practice Address - Country:US
Practice Address - Phone:651-232-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN21143207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP20018OtherHEALTHPARTNERS
MN01-22438OtherMEDICA CHOICE & PRIMARY
IA1540237Medicaid
MN66-07567OtherMEDICA CHOICE
MN102680OtherUCARE
MN97384BEOtherBCBS
MN341595300Medicaid
MN1000069OtherPREFERRED ONE
MN768021OtherARAZ
MN411743943OtherTRIWEST
MN01-22438OtherMEDICA CHOICE & PRIMARY
MN66-07567OtherMEDICA CHOICE
MN080190748Medicare ID - Type UnspecifiedRAILROAD MEDICARE