Provider Demographics
NPI:1063783678
Name:DR. MARY BERGE AND ASSOCIATES, LLC
Entity type:Organization
Organization Name:DR. MARY BERGE AND ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:IVAR
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-535-8586
Mailing Address - Street 1:1765 GOUCHER ST
Mailing Address - Street 2:STE 150
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-1101
Mailing Address - Country:US
Mailing Address - Phone:814-535-8586
Mailing Address - Fax:814-254-4170
Practice Address - Street 1:1765 GOUCHER ST
Practice Address - Street 2:STE 150
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15905-1101
Practice Address - Country:US
Practice Address - Phone:814-535-8586
Practice Address - Fax:814-254-4170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-13
Last Update Date:2017-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA168974251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019357340006POtherCBHNP
PA562719OtherVALUE BEHAVIORAL HEALTH
1483294OtherBCBS