Provider Demographics
NPI:1760516181
Name:BERG, ROBERT JACK
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:JACK
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 1:2925 N NEVADA ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99207-2761
Mailing Address - Country:US
Mailing Address - Phone:509-483-2283
Mailing Address - Fax:
Practice Address - Street 1:2925 N NEVADA ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99207-2761
Practice Address - Country:US
Practice Address - Phone:509-483-2283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist