Provider Demographics
NPI:1477530871
Name:BERG, MARY CHARLENE (CRNA)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:CHARLENE
Last Name:BERG
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 650426
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0426
Mailing Address - Country:US
Mailing Address - Phone:972-233-1999
Mailing Address - Fax:972-233-3666
Practice Address - Street 1:3535 S INTERSTATE 35 E
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76210-6850
Practice Address - Country:US
Practice Address - Phone:940-384-3270
Practice Address - Fax:940-384-4723
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX670102367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX162756402Medicaid
Q15853Medicare UPIN
TX8C9890Medicare ID - Type Unspecified606K