Basic Information
Provider Information | |||||||||
NPI: | 1477628527 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BERG | ||||||||
FirstName: | COLLEEN | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | N.P. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 370 FAUNCE CORNER ROAD | ||||||||
Address2: | SOUTHCOAST PHYSICIAN SERVICES, INC. | ||||||||
City: | NORTH DARTMOUTH | ||||||||
State: | MA | ||||||||
PostalCode: | 027471271 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5089852000 | ||||||||
FaxNumber: | 5089852001 | ||||||||
Practice Location | |||||||||
Address1: | 100 ROSEBROOK WAY | ||||||||
Address2: | SOUTHCOAST PHYSICIAN SERVICES, INC. 3RD FLOOR | ||||||||
City: | WAREHAM | ||||||||
State: | MA | ||||||||
PostalCode: | 025712097 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5082734900 | ||||||||
FaxNumber: | 5082734901 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/22/2006 | ||||||||
LastUpdateDate: | 06/16/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 142625 | MA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363LP0200X | 142625 | MA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363L00000X | RN142625 | MA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
No ID Information.