Healthcare Provider Details

I. General information

NPI: 1780649715
Provider Name (Legal Business Name): CRAIG BERGH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 10/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 S STATE ST STE 100
FAIRMONT MN
56031-4470
US

IV. Provider business mailing address

400 E 10TH ST
WACONIA MN
55387-4552
US

V. Phone/Fax

Practice location:
  • Phone: 507-235-3939
  • Fax:
Mailing address:
  • Phone: 952-442-9770
  • Fax: 952-442-3630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR142187-9
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: