Provider Demographics
NPI:1578008769
Name:BERG, RANDI LEIGH
Entity Type:Individual
Prefix:
First Name:RANDI
Middle Name:LEIGH
Last Name:BERG
Suffix:
Gender:F
Credentials:
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 372
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-0372
Mailing Address - Country:US
Mailing Address - Phone:217-868-2812
Mailing Address - Fax:217-258-2216
Practice Address - Street 1:5 E CUMBERLAND RD
Practice Address - Street 2:
Practice Address - City:ALTAMONT
Practice Address - State:IL
Practice Address - Zip Code:62411-1271
Practice Address - Country:US
Practice Address - Phone:618-483-6151
Practice Address - Fax:618-483-6153
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-27
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.016197363L00000X
IL209-016197363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner