Basic Information
| Provider Information | |||||||||
| NPI: | 1992952493 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERGER | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | EVAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 320 POPLAR ST | ||||||||
| Address2: | |||||||||
| City: | ROSLINDALE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021314339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8455510260 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 DEACONESS RD | ||||||||
| Address2: | WEST CLINICAL CENTER | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022155321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177542339 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2008 | ||||||||
| LastUpdateDate: | 02/02/2012 | ||||||||
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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 | 207P00000X | 232101 | MA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110087695A | 05 | MA | MEDICAID |