Provider Demographics
NPI:1982692596
Name:BERG, EVAN R (MD)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:R
Last Name:BERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:960 MASSACHUSETTS AVENUE
Mailing Address - Street 2:FL 2
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2690
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 BOSTON MEDICAL CTR PL
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2908
Practice Address - Country:US
Practice Address - Phone:617-414-5481
Practice Address - Fax:617-414-7759
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY232041207P00000X
MA215357207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3120664Medicaid
MA110007139AMedicaid
MA110007139AMedicaid
P00393926Medicare PIN
MAA34813Medicare PIN
MA110007139AMedicaid