Provider Demographics
NPI:1497729172
Name:BERGER, LISA MARIE (PA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:BERGER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:DUGA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5800 FOREMOST DR SE STE 300
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-7062
Mailing Address - Country:US
Mailing Address - Phone:616-954-9800
Mailing Address - Fax:
Practice Address - Street 1:145 MICHIGAN ST NE
Practice Address - Street 2:SUITE 3100
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2562
Practice Address - Country:US
Practice Address - Phone:616-954-9800
Practice Address - Fax:616-954-1724
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004069363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5410850OtherBCBSM PIN
MIM08620051Medicare PIN
MI5410850OtherBCBSM PIN