Provider Demographics
NPI:1780007799
Name:BERG, BETHANY
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:BERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 S 16TH ST
Mailing Address - Street 2:TRAUMA DEPARTMENT
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68502-3704
Mailing Address - Country:US
Mailing Address - Phone:402-481-4167
Mailing Address - Fax:402-481-5100
Practice Address - Street 1:2300 S 16TH ST
Practice Address - Street 2:TRAUMA DEPARTMENT
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68502-3704
Practice Address - Country:US
Practice Address - Phone:402-481-4167
Practice Address - Fax:402-481-5100
Is Sole Proprietor?:No
Enumeration Date:2014-01-27
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1786363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE096742004OtherMEDICARE ID