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Organization
MYRTLE RIDGE FAMILY MEDICINE, PA
Active
Organization
MYRTLE RIDGE FAMILY MEDICINE, PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JACK BERGH MD (CEO)
(813) 909-7102
Entity
Organization
Contact information
Practice address
1539 DALE MABRY HWY, 102, LUTZ, FL 33548-3008
(813) 909-7102
(813) 909-0199
Mailing address
PO BOX 660, LUTZ, FL 33548-0660
(813) 909-7102
(813) 909-0199
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
ME0056971
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
770008300
—
FL
Enumeration date
02/01/2007
Last updated
01/10/2013
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