Healthcare Provider Details

I. General information

NPI: 1518469774
Provider Name (Legal Business Name): SARA BERG PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2018
Last Update Date: 03/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 W CENTRAL AVE
SPRINGBORO OH
45066-1106
US

IV. Provider business mailing address

3170 KETTERING BLVD BLDG B 3RD FLOOR
MORAINE OH
45439-1924
US

V. Phone/Fax

Practice location:
  • Phone: 937-208-7100
  • Fax:
Mailing address:
  • Phone: 937-991-3188
  • Fax: 937-223-9811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number50.005496RX
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.005496RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: