Provider Demographics
NPI:1962576512
Name:BERG, GERALD C (DC)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:C
Last Name:BERG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18275 N 59TH AVE
Mailing Address - Street 2:BLDG A SUITE 106
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-1260
Mailing Address - Country:US
Mailing Address - Phone:602-375-2225
Mailing Address - Fax:602-942-5662
Practice Address - Street 1:18275 N 59TH AVE
Practice Address - Street 2:BLDG A SUITE 106
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-1260
Practice Address - Country:US
Practice Address - Phone:602-375-2225
Practice Address - Fax:602-942-5662
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7831 AND 4520 PHYSIO111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ100607OtherMEDICARE GROUP
AZ1962576512OtherBLUE CROSS BLUE SHIELD
AZ1477686541OtherMEDICARE NPI GROUP