Provider Demographics
NPI:1548326978
Name:BERG, MICHAEL LAWRENCE
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LAWRENCE
Last Name:BERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7316 MARBLETHORPE DR
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-5957
Mailing Address - Country:US
Mailing Address - Phone:916-780-9379
Mailing Address - Fax:
Practice Address - Street 1:2016 MORSE AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-2135
Practice Address - Country:US
Practice Address - Phone:916-973-7760
Practice Address - Fax:916-973-7739
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA262852363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner