Provider Demographics
NPI:1598199572
Name:BERG, MATTHEW DAVID
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:DAVID
Last Name:BERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 9TH ST N
Mailing Address - Street 2:SUITE 100
Mailing Address - City:VIRGINIA
Mailing Address - State:MN
Mailing Address - Zip Code:55792-2325
Mailing Address - Country:US
Mailing Address - Phone:218-749-9405
Mailing Address - Fax:218-749-9407
Practice Address - Street 1:901 9TH ST N
Practice Address - Street 2:SUITE 100
Practice Address - City:VIRGINIA
Practice Address - State:MN
Practice Address - Zip Code:55792-2325
Practice Address - Country:US
Practice Address - Phone:218-749-9405
Practice Address - Fax:218-749-9407
Is Sole Proprietor?:No
Enumeration Date:2013-08-27
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6774225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist