Basic Information
| Provider Information | |||||||||
| NPI: | 1063491751 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERGER | ||||||||
| FirstName: | LONNIE | ||||||||
| MiddleName: | WILLIAM | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 712 S CASCADE ST | ||||||||
| Address2: | |||||||||
| City: | FERGUS FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565372913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187368000 | ||||||||
| FaxNumber: | 2187396718 | ||||||||
| Practice Location | |||||||||
| Address1: | 712 S CASCADE ST | ||||||||
| Address2: | |||||||||
| City: | FERGUS FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565372913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187368000 | ||||||||
| FaxNumber: | 2187396718 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2006 | ||||||||
| LastUpdateDate: | 02/17/2017 | ||||||||
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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 | 207Q00000X | 38597 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 255016400 | 05 | MN | MEDICAID |