Provider Demographics
NPI:1114901063
Name:BERG, ROBERT JOHN (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:JOHN
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 1:2024 15TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-4130
Mailing Address - Country:US
Mailing Address - Phone:601-482-5174
Mailing Address - Fax:601-482-5175
Practice Address - Street 1:2024 15TH ST
Practice Address - Street 2:SUITE 500
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4130
Practice Address - Country:US
Practice Address - Phone:601-482-5174
Practice Address - Fax:601-482-5175
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS06978174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018061Medicaid
MS73006066OtherBLUE CROSS ALABAMA
MSC00332Medicare PIN
MS73006066OtherBLUE CROSS ALABAMA