Provider Demographics
NPI:1770767782
Name:BERG MEDICAL CLINIC PC
Entity type:Organization
Organization Name:BERG MEDICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHUBLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-854-9100
Mailing Address - Street 1:221 CALUMET AVE SW
Mailing Address - Street 2:
Mailing Address - City:DE SMET
Mailing Address - State:SD
Mailing Address - Zip Code:57231
Mailing Address - Country:US
Mailing Address - Phone:605-854-9100
Mailing Address - Fax:605-854-9238
Practice Address - Street 1:221 CALUMET AVE SW
Practice Address - Street 2:
Practice Address - City:DE SMET
Practice Address - State:SD
Practice Address - Zip Code:57231
Practice Address - Country:US
Practice Address - Phone:605-854-9100
Practice Address - Fax:605-854-9238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDSD 4247207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD4996058OtherSD BLUE SHIELD
SD5602487Medicaid
SD5602487Medicaid