Provider Demographics
NPI:1104866771
Name:BERG, ELIZABETH M (CPNP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:M
Last Name:BERG
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:9 RICHLAND MEDICAL PARK DR STE 500
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6870
Practice Address - Country:US
Practice Address - Phone:803-434-4555
Practice Address - Fax:803-434-4599
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN142363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA3422F935OtherMEDICARE
SCNP1724Medicaid
SCNP1724Medicaid