Provider Demographics
NPI:1720182256
Name:BERG, FANNY J (MD)
Entity Type:Individual
Prefix:DR
First Name:FANNY
Middle Name:J
Last Name:BERG
Suffix:
Gender:F
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:302-475-8000
Mailing Address - Fax:302-475-8043
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:302-475-8000
Practice Address - Fax:302-475-8043
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0002879174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000035901Medicaid
DE075162Medicare ID - Type Unspecified
DED01084Medicare UPIN