Provider Demographics
NPI:1841203676
Name:BERG, WENDIE
Entity Type:Individual
Prefix:
First Name:WENDIE
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 1:10373A REISTERSTOWN RD
Mailing Address - Street 2:SUITE 3950
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-3617
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21 CROSSROADS DR
Practice Address - Street 2:STE 100
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-5441
Practice Address - Country:US
Practice Address - Phone:410-356-8186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00395642085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC2849OtherB/C B/S
MD754621100Medicaid
MDKA80OtherB/C B/S
MDJ062OtherB/C B/S
MD754621100Medicaid
MDJ062OtherB/C B/S
DC2849OtherB/C B/S
MDF32141Medicare UPIN
MD435LG576Medicare ID - Type UnspecifiedLOCALITY/JURIS. CODE 02
MDCD4495Medicare ID - Type UnspecifiedRAILROAD MEDICARE