Healthcare Provider Details

I. General information

NPI: 1295817336
Provider Name (Legal Business Name): BRYAN JOHN BERGH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 08/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 NICOLLET AVE.
MINNEAPOLIS MN
55403
US

IV. Provider business mailing address

525 PORTLAND AVE HSB MC 952
MINNEAPOLIS MN
55415-1533
US

V. Phone/Fax

Practice location:
  • Phone: 612-348-9840
  • Fax: 612-596-7900
Mailing address:
  • Phone: 612-348-9840
  • Fax: 612-596-7900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number32374
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: