Healthcare Provider Details

I. General information

NPI: 1174609648
Provider Name (Legal Business Name): CAY E BERG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 S WACKERLI AVE
AMMON ID
83406-8154
US

IV. Provider business mailing address

4701 S WACKERLI AVE
AMMON ID
83406-8154
US

V. Phone/Fax

Practice location:
  • Phone: 208-542-1963
  • Fax:
Mailing address:
  • Phone: 208-542-1963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License NumberM-8652
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: