Provider Demographics
NPI:1679682868
Name:BERGER, PAUL EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:EDWARD
Last Name:BERGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5171 S SEEWEEWANA CT
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:ID
Mailing Address - Zip Code:83833-6051
Mailing Address - Country:US
Mailing Address - Phone:208-771-0641
Mailing Address - Fax:
Practice Address - Street 1:5171 S SEEWEEWANA CT
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:ID
Practice Address - Zip Code:83833-6051
Practice Address - Country:US
Practice Address - Phone:220-877-1064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM69502085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDF51051Medicare UPIN