Provider Demographics
NPI:1376312751
Name:BERG, MICHAEL MARTIN
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:MARTIN
Last Name:BERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 PARK ST
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669-3911
Mailing Address - Country:US
Mailing Address - Phone:315-713-9090
Mailing Address - Fax:
Practice Address - Street 1:1003 PARK ST
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669-3911
Practice Address - Country:US
Practice Address - Phone:315-713-9090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-27
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist