Provider Demographics
NPI:1083698997
Name:BERG, GARY L (DO)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:L
Last Name:BERG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:29992 NORTHWESTERN HWY STE C
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-3292
Mailing Address - Country:US
Mailing Address - Phone:248-851-1430
Mailing Address - Fax:248-851-5182
Practice Address - Street 1:27483 DEQUINDRE RD
Practice Address - Street 2:SUITE 210
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-3491
Practice Address - Country:US
Practice Address - Phone:248-398-4081
Practice Address - Fax:248-398-4527
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2018-12-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5101008535207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIB46457OtherHAP
MI290003024OtherRR MEDICARE
MI5630250OtherBCBS INDIVIDUAL
MI1083698997Medicaid
MIB46457Medicare UPIN
MI0M92440029Medicare PIN