Basic Information
| Provider Information | |||||||||
| NPI: | 1467497610 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERGH | ||||||||
| FirstName: | KENT | ||||||||
| MiddleName: | DAVIS | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 KENNARD ST | ||||||||
| Address2: | SUITE 100 HEALTHEAST MAPLEWOOD CLINIC, | ||||||||
| City: | MAPLEWOOD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512327800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3100 KENNARD ST | ||||||||
| Address2: | SUITE 100 HEALTHEAST PHYSICIAN SERVICE, | ||||||||
| City: | MAPLEWOOD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512327800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 06/08/2010 | ||||||||
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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 | 207Q00000X | 21143 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | HP20018 | 01 | MN | HEALTHPARTNERS | OTHER | 01-22438 | 01 | MN | MEDICA CHOICE & PRIMARY | OTHER | 1540237 | 05 | IA | MEDICAID | 66-07567 | 01 | MN | MEDICA CHOICE | OTHER | 102680 | 01 | MN | UCARE | OTHER | 97384BE | 01 | MN | BCBS | OTHER | 341595300 | 05 | MN | MEDICAID | 1000069 | 01 | MN | PREFERRED ONE | OTHER | 768021 | 01 | MN | ARAZ | OTHER | 411743943 | 01 | MN | TRIWEST | OTHER |