Healthcare Provider Details

I. General information

NPI: 1336352939
Provider Name (Legal Business Name): MARY EILEEN BERG NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 11/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N MOUNTAIN AVE SUITE A104
UPLAND CA
91786-4359
US

IV. Provider business mailing address

536 E MARIPOSA ST
UPLAND CA
91784-2071
US

V. Phone/Fax

Practice location:
  • Phone: 909-931-1033
  • Fax: 909-981-8976
Mailing address:
  • Phone: 909-931-1033
  • Fax: 909-981-8976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number389253
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: