Provider Demographics
NPI:1861614612
Name:BERG, CHRISTINE DOROTHY (MD)
Entity type:Individual
Prefix:DR
First Name:CHRISTINE
Middle Name:DOROTHY
Last Name:BERG
Suffix:
Gender:F
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:EXECUTIVE PLAZA NORTH, ROOM 3100
Mailing Address - Street 2:6130 EXECUTIVE BLVD.
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20892-7346
Mailing Address - Country:US
Mailing Address - Phone:301-496-8544
Mailing Address - Fax:301-480-0465
Practice Address - Street 1:EXECUTIVE PLAZA NORTH, ROOM 3100
Practice Address - Street 2:6130 EXECUTIVE BLVD.
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20892-7346
Practice Address - Country:US
Practice Address - Phone:301-496-8544
Practice Address - Fax:301-480-0465
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD28954174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDC89081Medicare UPIN