Basic Information
Provider Information | |||||||||
NPI: | 1972506202 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BERG | ||||||||
FirstName: | SUSAN | ||||||||
MiddleName: | E. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | A.R.N.P. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1701 NW HAWTHORNE AVE | ||||||||
Address2: | SUITE 201 | ||||||||
City: | GRANTS PASS | ||||||||
State: | OR | ||||||||
PostalCode: | 975261257 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5414713455 | ||||||||
FaxNumber: | 5414711439 | ||||||||
Practice Location | |||||||||
Address1: | 25647 REDWOOD HWY | ||||||||
Address2: |   | ||||||||
City: | CAVE JUNCTION | ||||||||
State: | OR | ||||||||
PostalCode: | 975239332 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5415924111 | ||||||||
FaxNumber: | 5415923916 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/31/2005 | ||||||||
LastUpdateDate: | 01/21/2014 | ||||||||
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 | 364S00000X | AP30006914 | WA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist |   |
No ID Information.