Healthcare Provider Details

I. General information

NPI: 1114996782
Provider Name (Legal Business Name): BRIAN BERGER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 10/07/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44201 DEQUINDRE RD
TROY MI
48085-1117
US

IV. Provider business mailing address

26901 BEAUMONT BLVD # 3-D
SOUTHFIELD MI
48033-3849
US

V. Phone/Fax

Practice location:
  • Phone: 248-964-5190
  • Fax:
Mailing address:
  • Phone: 248-577-9221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4301059563
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: