Healthcare Provider Details

I. General information

NPI: 1043210180
Provider Name (Legal Business Name): DAWN M DETWILER BERGER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 02/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54938 STATE ROAD 13
MIDDLEBURY IN
46540-8608
US

IV. Provider business mailing address

2310 CALIFORNIA ROAD
ELKHART IN
46514-1228
US

V. Phone/Fax

Practice location:
  • Phone: 574-825-8685
  • Fax: 574-825-1256
Mailing address:
  • Phone: 574-264-4163
  • Fax: 574-262-9650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01045293A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number01045293
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: