Healthcare Provider Details

I. General information

NPI: 1770767782
Provider Name (Legal Business Name): BERG MEDICAL CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 01/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 CALUMET AVE SW
DE SMET SD
57231
US

IV. Provider business mailing address

221 CALUMET AVE SW
DE SMET SD
57231
US

V. Phone/Fax

Practice location:
  • Phone: 605-854-9100
  • Fax: 605-854-9238
Mailing address:
  • Phone: 605-854-9100
  • Fax: 605-854-9238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberSD 4247
License Number StateSD

VIII. Authorized Official

Name: JANELLE SCHUBLOOM
Title or Position: OFFICE MANAGER
Credential:
Phone: 605-854-9100