Provider Demographics
NPI:1881660207
Name:KEVIN C. BERG, O.D., LLC
Entity Type:Organization
Organization Name:KEVIN C. BERG, O.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:CRAIG
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:907-376-0835
Mailing Address - Street 1:1350 S SEWARD MERIDIAN PKWY
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-8332
Mailing Address - Country:US
Mailing Address - Phone:907-376-0835
Mailing Address - Fax:907-376-0843
Practice Address - Street 1:1350 S SEWARD MERIDIAN PKWY
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8332
Practice Address - Country:US
Practice Address - Phone:907-376-0835
Practice Address - Fax:907-376-0843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-25
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK104152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKOD1144Medicaid
AKK0000PHLCRMedicare PIN
AKOD1144Medicaid