1730590639 NPI number — KELSEY J BERG

Table of content: KELSEY J BERG (NPI 1730590639)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730590639 NPI number — KELSEY J BERG

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERG
Provider First Name:
KELSEY
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730590639
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/14/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
167 S CONWELL ST STE 3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CASPER
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82601-2749
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-233-0246
Provider Business Mailing Address Fax Number:
307-237-5421

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1020 E 2ND ST
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
CASPER
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82601-2946
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-577-8832
Provider Business Practice Location Address Fax Number:
307-237-5421
Provider Enumeration Date:
05/13/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  OTR 765 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: OTR 765 . This is a "WYOMING STATE LICENSE NUMBER" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".




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