Basic Information
| Provider Information | |||||||||
| NPI: | 1124286604 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERG | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | ADAM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 GROVE ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | HADDON HEIGHTS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080351761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567969200 | ||||||||
| FaxNumber: | 8567969397 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 WHITE HORSE PIKE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | HADDON HEIGHTS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080351938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565463900 | ||||||||
| FaxNumber: | 8565463908 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2008 | ||||||||
| LastUpdateDate: | 03/21/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 25MA08642000 | NJ | N | Allopathic & Osteopathic Physicians | Surgery | 208C00000X | 25MA08642000 | NJ | N | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery | 208600000X | MD426634 | PA | N | Allopathic & Osteopathic Physicians | Surgery | 208C00000X | MD426634 | PA | Y | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0212563 | 05 | NJ | MEDICAID |