Basic Information
Provider Information | |||||||||
NPI: | 1801883558 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BERG | ||||||||
FirstName: | RICHARD | ||||||||
MiddleName: | A. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 45640 SCHOENHERR RD | ||||||||
Address2: | SUITE B | ||||||||
City: | SHELBY TOWNSHIP | ||||||||
State: | MI | ||||||||
PostalCode: | 483156033 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5862474300 | ||||||||
FaxNumber: | 5865326496 | ||||||||
Practice Location | |||||||||
Address1: | 22201 MOROSS RD | ||||||||
Address2: | SUITE 155 | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 482362169 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5862474300 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/28/2005 | ||||||||
LastUpdateDate: | 02/08/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 4301041478 | MI | Y |   | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
ID | Type | State | Issuer | Description | 1846920 | 05 | MI |   | MEDICAID | 020H21281 | 01 |   | BCBSM | OTHER |