Healthcare Provider Details

I. General information

NPI: 1376637421
Provider Name (Legal Business Name): TRACY A BERG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TRACY A MAGNUSON MD

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 12/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16201 E INDIANA AVE STE 3100
SPOKANE VALLEY WA
99216-2830
US

IV. Provider business mailing address

16201 E INDIANA AVE STE 3100
SPOKANE VALLEY WA
99216-2830
US

V. Phone/Fax

Practice location:
  • Phone: 509-891-8904
  • Fax: 509-344-3104
Mailing address:
  • Phone: 509-891-8904
  • Fax: 509-344-3104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberMD00032615
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: