Healthcare Provider Details

I. General information

NPI: 1093703605
Provider Name (Legal Business Name): PAUL J BERGGREEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 02/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 N 12TH ST #613
PHOENIX AZ
85006-2848
US

IV. Provider business mailing address

3020 E CAMELBACK RD SUITE 301
PHOENIX AZ
85016-5059
US

V. Phone/Fax

Practice location:
  • Phone: 602-254-5321
  • Fax: 602-254-6582
Mailing address:
  • Phone: 602-264-9100
  • Fax: 602-264-9101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number21349
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: