Provider Demographics
NPI:1174524391
Name:BERG, MARY ELLEN (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:BERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:471 ASHLEY RIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106
Mailing Address - Country:US
Mailing Address - Phone:318-795-4770
Mailing Address - Fax:318-795-4775
Practice Address - Street 1:471 ASHLEY RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106
Practice Address - Country:US
Practice Address - Phone:318-795-4770
Practice Address - Fax:318-795-4775
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA019001207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR123802001OtherARKANSAS MEDICAID
LA1053315846OtherGROUP MEDICARE NUMBER
LA1922871Medicaid
TX078737601OtherTEXAS MEDICAID
LAP00375906OtherRAILROAD MEDICARE
LAP00375906OtherRAILROAD MEDICARE
AR123802001OtherARKANSAS MEDICAID
LAE78009Medicare UPIN
LA5N0046742Medicare PIN