Provider Demographics
NPI:1184642332
Name:BERG, MICHAEL ALLEN (DC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALLEN
Last Name:BERG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 360
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:IL
Mailing Address - Zip Code:62294-0360
Mailing Address - Country:US
Mailing Address - Phone:618-667-0600
Mailing Address - Fax:
Practice Address - Street 1:805 LIONS DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:IL
Practice Address - Zip Code:62294-2440
Practice Address - Country:US
Practice Address - Phone:618-667-0600
Practice Address - Fax:618-667-8189
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-007911111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK04391OtherPTAN
ILK04391OtherPTAN
ILK04391Medicare Oscar/Certification