Provider Information for 1376090498
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SCOTT BERG isw 9192
Sex: Male
NPI: 1376090498
Last Updated: 2021-11-29
Certification Date: 2021-11-29
Certification Date: 2021-11-29
Details
| Name | Value | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| NPI | 1376090498 | ||||||||||||
| Enumeration Date | 2016-09-07 | ||||||||||||
| NPI Type | NPI-1 Individual | ||||||||||||
| Sole Proprietor | NO | ||||||||||||
| Status | Active | ||||||||||||
| Mailing Address | 528 CARRERA DR LADY LAKE, FL 32159-9249 United States Phone: 352-446-0995 | Fax: | ||||||||||||
| Primary Practice Address | 2140 N DON WICKHAM DR CLERMONT, FL 34711-1922 United States Phone: 352-394-5322 | Fax:352-394-1103 | ||||||||||||
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