Basic Information
| Provider Information | |||||||||
| NPI: | 1306920574 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERGER | ||||||||
| FirstName: | WALTER | ||||||||
| MiddleName: | JESSE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | PHD, MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 ELM ST N | ||||||||
| Address2: | VA MEDICAL CENTER | ||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581022417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012323241 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2101 ELM ST N | ||||||||
| Address2: | VA MEDICAL CENTER | ||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581022417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012323241 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 04/17/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 47619 | MN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 12923 | 05 | ND | MEDICAID |