Healthcare Provider Details

I. General information

NPI: 1053492827
Provider Name (Legal Business Name): TONY L BERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 10/25/2022
Certification Date: 10/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 JACKSON ST
BURKE SD
57523-2065
US

IV. Provider business mailing address

PO BOX 319
BURKE SD
57523-0319
US

V. Phone/Fax

Practice location:
  • Phone: 605-775-2631
  • Fax: 605-775-2564
Mailing address:
  • Phone: 605-775-2631
  • Fax: 605-775-2564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2460
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: