=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245221647
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK A BERG MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2005
-----------------------------------------------------
Last Update Date | 10/31/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1400 1ST ST NE
-----------------------------------------------------
City | NEW PRAGUE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56071-2215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-758-2535
-----------------------------------------------------
Fax | 952-548-6160
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 580 RICE ST
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55103-2148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-227-6551
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 38780
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208M00000X
-----------------------------------------------------
Taxonomy Name | Hospitalist Physician
-----------------------------------------------------
License Number | ME174964
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 38780
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207QG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 38780
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 38780
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 207QA0000X
-----------------------------------------------------
Taxonomy Name | Adolescent Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 38780
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------