Provider Demographics
NPI:1992952493
Name:BERGER, RUSSELL EVAN (MD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:EVAN
Last Name:BERGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-4339
Mailing Address - Country:US
Mailing Address - Phone:845-551-0260
Mailing Address - Fax:
Practice Address - Street 1:1 DEACONESS RD
Practice Address - Street 2:WEST CLINICAL CENTER
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5321
Practice Address - Country:US
Practice Address - Phone:617-754-2339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-26
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA232101207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110087695AMedicaid