Basic Information
Provider Information
NPI: 1003140328
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BERGER
FirstName: CAROL
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
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OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 106 BROADWAY ST
Address2: SUITE 3C
City: ELSBERRY
State: MO
PostalCode: 633431345
CountryCode: US
TelephoneNumber: 5738989100
FaxNumber: 5738989102
Practice Location
Address1: 106 BROADWAY ST
Address2: SUITE 3C
City: ELSBERRY
State: MO
PostalCode: 633431345
CountryCode: US
TelephoneNumber: 5738989100
FaxNumber: 5738989102
Other Information
ProviderEnumerationDate: 09/21/2009
LastUpdateDate: 09/15/2011
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
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AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363LF0000X136468MOY Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily

No ID Information.


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