Provider Demographics
NPI:1932279718
Name:BERG, BRUCE JEFFREY (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:JEFFREY
Last Name:BERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 FOULK RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19810-3642
Mailing Address - Country:US
Mailing Address - Phone:610-527-6555
Mailing Address - Fax:
Practice Address - Street 1:2000 FOULK RD
Practice Address - Street 2:SUITE A
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19810-3642
Practice Address - Country:US
Practice Address - Phone:610-527-6555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-037544-E2084P0800X, 2084P0802X
DEC1-00039742084P0800X
PAMD037544E2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAC31427Medicare UPIN
PA137461Medicare ID - Type Unspecified