Provider Demographics
NPI:1114948817
Name:BERG, RICHARD A (PHD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:A
Last Name:BERG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5010 RANDALL PKWY
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-2829
Mailing Address - Country:US
Mailing Address - Phone:910-791-5719
Mailing Address - Fax:910-799-8180
Practice Address - Street 1:5010 RANDALL PKWY
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-2829
Practice Address - Country:US
Practice Address - Phone:910-791-5719
Practice Address - Fax:910-799-8180
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1976103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
A206244OtherGROUP
280096 PINOtherVALUE OPTIONS
B5232OtherMEDCOST
61-00496OtherUNITED HEALTHCARE
NC0334HOtherBLUE CROSS BLUE SHIELD
5777071OtherAETNA
07740OtherMAGALLEN
5777071OtherAETNA
NC2814809EMedicare PIN