Provider Demographics
NPI:1073803391
Name:BERG, RYAN (MD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:BERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3070 N 51ST ST STE 207
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53210-1661
Mailing Address - Country:US
Mailing Address - Phone:414-874-4870
Mailing Address - Fax:
Practice Address - Street 1:3070 N 51ST ST STE 207
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-1661
Practice Address - Country:US
Practice Address - Phone:414-874-4870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-08
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI59063208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery