Provider Demographics
NPI:1992818272
Name:BERG, BONNIE L (DC)
Entity type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:L
Last Name:BERG
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-6160
Mailing Address - Country:US
Mailing Address - Phone:781-396-1070
Mailing Address - Fax:781-396-6607
Practice Address - Street 1:314 MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-6160
Practice Address - Country:US
Practice Address - Phone:781-396-1070
Practice Address - Fax:781-396-6607
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1118111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA713630OtherTUFTS NUMBER
MA4130676OtherAETNA NUMBER
MA351243OtherHARVARD/PILGRAM NUMBER
MAY35828Medicare ID - Type UnspecifiedMEDICARE AND BCBS NUMBERS