Provider Demographics
NPI:1952527111
Name:TRACY A BERG M.D., P.S.
Entity type:Organization
Organization Name:TRACY A BERG M.D., P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PS
Authorized Official - Phone:509-344-3100
Mailing Address - Street 1:235 E ROWAN AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99207-1240
Mailing Address - Country:US
Mailing Address - Phone:509-344-3100
Mailing Address - Fax:509-344-3104
Practice Address - Street 1:235 E ROWAN AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99207-1240
Practice Address - Country:US
Practice Address - Phone:509-344-3100
Practice Address - Fax:509-344-3104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000032615208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1123884Medicaid
WAG10477Medicare UPIN
WA1123884Medicaid