Provider Demographics
NPI:1508809831
Name:BERG, STEPHANIE LISA (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:LISA
Last Name:BERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:LISA
Other - Last Name:ROSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:11 RICHLAND MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6863
Practice Address - Country:US
Practice Address - Phone:803-434-4506
Practice Address - Fax:803-434-1537
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA359192084P0800X
SC312212084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC312218Medicaid
IA0727552Medicaid
IA20148OtherWELLMARK BCBS
I59264Medicare UPIN
SCAA3422F935Medicare PIN
IAI17951Medicare PIN
IA20148OtherWELLMARK BCBS