Provider Demographics
NPI:1902804313
Name:BERG, GEOFFREY HERBST (MD)
Entity Type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:HERBST
Last Name:BERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 WAYLAND AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-4304
Mailing Address - Country:US
Mailing Address - Phone:401-521-1221
Mailing Address - Fax:401-454-4189
Practice Address - Street 1:160 WAYLAND AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-4304
Practice Address - Country:US
Practice Address - Phone:401-521-1221
Practice Address - Fax:401-454-4189
Is Sole Proprietor?:No
Enumeration Date:2005-07-09
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI05035207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI405576OtherBLUE CHIP
455099OtherTUFTS
RI7001787Medicaid
RI2919OtherBCBS
04-02664OtherUNITED HEALTH CARE
04-02664OtherUNITED HEALTH CARE
D87547Medicare UPIN