MEDICARE: DAWN M DETWILER BERGER MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207PE0004X	Emergency Medical Services (Emergency Medicine) Physician	01045293	IN
2	207P00000X	Emergency Medicine Physician	01045293A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043210180
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAWN M DETWILER BERGER MD

Provider Business Mailing Address
First Line	:	2310 CALIFORNIA ROAD
Second Line	:
City	:	ELKHART
State	:	IN
Zip	:	46514-1228
Country	:	US
Telephone Number	:	574-264-4163
Fax Number	:	574-262-9650

Provider Business Practice Location Address
First Line	:	54938 STATE ROAD 13
Second Line	:
City	:	MIDDLEBURY
State	:	IN
Zip	:	46540-8608
Country	:	US
Telephone Number	:	574-825-8685
Fax Number	:	574-825-1256

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/29/2005
Last Update Date	:	02/02/2010

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