Provider Demographics
NPI:1457321226
Name:BERG, JOHN ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ANDREW
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 1:221 CALUMET AVE SW
Mailing Address - Street 2:
Mailing Address - City:DESMET
Mailing Address - State:SD
Mailing Address - Zip Code:57231
Mailing Address - Country:US
Mailing Address - Phone:605-854-9100
Mailing Address - Fax:605-854-9238
Practice Address - Street 1:221 CALUMET AVE SW
Practice Address - Street 2:
Practice Address - City:DESMET
Practice Address - State:SD
Practice Address - Zip Code:57231
Practice Address - Country:US
Practice Address - Phone:605-854-9100
Practice Address - Fax:605-854-9238
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4247207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5602487Medicaid
23509OtherSIOUX VALLEY
4996058OtherSD BLUE SHIELD
SD5602487Medicaid
4996058OtherSD BLUE SHIELD