Basic Information
Provider Information | |||||||||
NPI: | 1265619696 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BERG | ||||||||
FirstName: | ERIC | ||||||||
MiddleName: | EDWARD | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5461 MERIDIAN MARKS RD STE 130 | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303423009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4042552033 | ||||||||
FaxNumber: | 4042521901 | ||||||||
Practice Location | |||||||||
Address1: | 5461 MERIDIAN MARKS RD STE 130 | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 30342 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4042552033 | ||||||||
FaxNumber: | 4042521901 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/28/2008 | ||||||||
LastUpdateDate: | 05/31/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YP0228X | 78940 | GA | Y |   | Allopathic & Osteopathic Physicians | Otolaryngology | Pediatric Otolaryngology | 207Y00000X | P2593 | TX | N |   | Allopathic & Osteopathic Physicians | Otolaryngology |   | 207Y00000X | MD441701 | PA | N |   | Allopathic & Osteopathic Physicians | Otolaryngology |   | 207YP0228X | MD441701 | PA | N |   | Allopathic & Osteopathic Physicians | Otolaryngology | Pediatric Otolaryngology | 207YP0228X | P2593 | TX | N |   | Allopathic & Osteopathic Physicians | Otolaryngology | Pediatric Otolaryngology |
ID Information
ID | Type | State | Issuer | Description | 003199122 | 05 | GA |   | MEDICAID |