Healthcare Provider Details

I. General information

NPI: 1396749792
Provider Name (Legal Business Name): KEVIN BERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 12/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 W MOUNTAIN VIEW AVE
LONGMONT CO
80501-3128
US

IV. Provider business mailing address

1925 W MOUNTAIN VIEW AVE
LONGMONT CO
80501-3128
US

V. Phone/Fax

Practice location:
  • Phone: 303-776-1234
  • Fax: 720-494-3107
Mailing address:
  • Phone: 303-776-1234
  • Fax: 720-494-3107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number26055
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: