Provider Demographics
NPI:1447219951
Name:BERG, JILL C (NP-C)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:C
Last Name:BERG
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:MEDPARTNERS, ATTN: BARB COPELAND
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-479-3514
Mailing Address - Fax:260-479-3520
Practice Address - Street 1:7916 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4140
Practice Address - Country:US
Practice Address - Phone:260-432-2297
Practice Address - Fax:260-434-6433
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2016-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001258A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
500022462OtherRAILROAD
IN000000289365OtherANTHEM
IN200353910Medicaid
OH2454348Medicaid
IN200353910Medicaid
OH2454348Medicaid
IN058490EEMedicare ID - Type Unspecified
IN200353910Medicaid