Healthcare Provider Details

I. General information

NPI: 1417941006
Provider Name (Legal Business Name): SARA A BERG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 06/29/2010
Certification Date:
Deactivation Date: 03/25/2006
Reactivation Date: 09/13/2006

III. Provider practice location address

1623 5TH ST SUITE B
CLARKSTON WA
99403
US

IV. Provider business mailing address

1623 5TH ST SUITE B
CLARKSTON WA
99403
US

V. Phone/Fax

Practice location:
  • Phone: 509-758-0128
  • Fax: 509-758-0402
Mailing address:
  • Phone: 509-758-0128
  • Fax: 509-758-0402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD00029192
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberM5872
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: