Healthcare Provider Details

I. General information

NPI: 1972747871
Provider Name (Legal Business Name): MICAH AVNER BERMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2009
Last Update Date: 10/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 UNIVERSITY AVE E
SAINT PAUL MN
55101-2507
US

IV. Provider business mailing address

200 UNIVERSITY AVE E
SAINT PAUL MN
55101-2507
US

V. Phone/Fax

Practice location:
  • Phone: 651-291-2848
  • Fax: 651-602-6885
Mailing address:
  • Phone: 651-291-2848
  • Fax: 651-602-6885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number59658
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number59658
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number59658
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: