Provider Demographics
NPI:1629391776
Name:MARK D. BERGER, M.D., S.C.
Entity Type:Organization
Organization Name:MARK D. BERGER, M.D., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:DAVE
Authorized Official - Last Name:BERGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-782-0292
Mailing Address - Street 1:30 N MICHIGAN AVE
Mailing Address - Street 2:SUITE 901
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-3767
Mailing Address - Country:US
Mailing Address - Phone:312-782-0292
Mailing Address - Fax:
Practice Address - Street 1:30 N MICHIGAN AVE STE 901
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-3767
Practice Address - Country:US
Practice Address - Phone:312-782-0292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-03
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3636630102L00000X
IL042.000349036.033630102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalystGroup - Single Specialty