Provider Demographics
NPI:1265646806
Name:BERG, NATHANIEL BENJAMIN (MD)
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:BENJAMIN
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 1:633 GOVERNOR CARLOS CAMACHO ROAD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96913
Mailing Address - Country:US
Mailing Address - Phone:671-649-1001
Mailing Address - Fax:671-649-1002
Practice Address - Street 1:633 GOVERNOR CARLOS CAMACHO ROAD
Practice Address - Street 2:SUITE 210
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913
Practice Address - Country:US
Practice Address - Phone:671-649-1001
Practice Address - Fax:671-649-1002
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUM-11422085N0904X, 2085R0202X, 208VP0014X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G74735Medicare UPIN
52220Medicare ID - Type Unspecified