Basic Information
| Provider Information | |||||||||
| NPI: | 1639142086 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERG | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 EAST PENN SQUARE | ||||||||
| Address2: | THE WANAMAKER BUILDING, 9TH FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191073323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2674259300 | ||||||||
| FaxNumber: | 2674259331 | ||||||||
| Practice Location | |||||||||
| Address1: | 324 S. 34TH STREET | ||||||||
| Address2: | SUITE 9329 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191044399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155901858 | ||||||||
| FaxNumber: | 2155904327 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 03/11/2013 | ||||||||
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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 | 2080P0203X | 10695 | AZ | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 2080P0203X | MD434817 | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 277021 | 05 | AZ | MEDICAID | 132339EMD | 01 | PA | MEDICARE PTAN | OTHER | 1021962790001 | 05 | PA | MEDICAID | ZWCGCR | 01 | AZ | GROUP MEDICARE NUMBER | OTHER |