Basic Information
| Provider Information | |||||||||
| NPI: | 1578008769 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERG | ||||||||
| FirstName: | RANDI | ||||||||
| MiddleName: | LEIGH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1005 HEALTH CENTER DR STE 201 | ||||||||
| Address2: | |||||||||
| City: | MATTOON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619384653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178682812 | ||||||||
| FaxNumber: | 2172582216 | ||||||||
| Practice Location | |||||||||
| Address1: | 8 N 3RD ST | ||||||||
| Address2: | |||||||||
| City: | ALTAMONT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624111408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184836151 | ||||||||
| FaxNumber: | 6184836153 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2016 | ||||||||
| LastUpdateDate: | 08/16/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 209-016197 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 209.016197 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.