Provider Demographics
NPI:1780007799
Name:BERG, BETHANY
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:BERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4350 DEWEY AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68105-1017
Mailing Address - Country:US
Mailing Address - Phone:402-552-6007
Mailing Address - Fax:
Practice Address - Street 1:4350 DEWEY AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68105-1017
Practice Address - Country:US
Practice Address - Phone:402-552-6007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-27
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1786363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE096742004OtherMEDICARE ID