=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205818804
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GARY LEE BERGER MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2005
-----------------------------------------------------
Last Update Date | 04/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2400 HARBOR BLVD SUITE 21
-----------------------------------------------------
City | PORT CHARLOTTE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33952-5052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-625-6992
-----------------------------------------------------
Fax | 941-625-7238
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2234 COLONIAL BLVD MANAGED CARE DEPARTMENT
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33907-1412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-931-7342
-----------------------------------------------------
Fax | 239-931-7385
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number | ME0030516
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------