Provider Demographics
NPI:1891747739
Name:BERG, DAVID (PA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:BERG
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 826186
Mailing Address - Street 2:DAVID BERG PA
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182
Mailing Address - Country:US
Mailing Address - Phone:800-795-5820
Mailing Address - Fax:
Practice Address - Street 1:4295 HEMPSTEAD TURNPIKE
Practice Address - Street 2:ER DEPT ISLAND MEDICAL PHYSICIANS
Practice Address - City:BETH PAGE
Practice Address - State:NY
Practice Address - Zip Code:11714
Practice Address - Country:US
Practice Address - Phone:516-579-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010964363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02773040Medicare PIN
Q69195Medicare UPIN
P00392218Medicare PIN