Basic Information
| Provider Information | |||||||||
| NPI: | 1467900951 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERG | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 92987 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441943436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409972262 | ||||||||
| FaxNumber: | 4409976507 | ||||||||
| Practice Location | |||||||||
| Address1: | 2420 LAKE AVE | ||||||||
| Address2: | |||||||||
| City: | ASHTABULA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440044954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409980322 | ||||||||
| FaxNumber: | 4409984525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2016 | ||||||||
| LastUpdateDate: | 09/14/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F06161721 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.