Provider Demographics
NPI:1598769150
Name:BERG, RANDI KIRSTEN (MD)
Entity Type:Individual
Prefix:
First Name:RANDI
Middle Name:KIRSTEN
Last Name:BERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1836 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5429
Mailing Address - Country:US
Mailing Address - Phone:608-782-7300
Mailing Address - Fax:
Practice Address - Street 1:805 MAIN AVE S
Practice Address - Street 2:
Practice Address - City:HARMONY
Practice Address - State:MN
Practice Address - Zip Code:55939-6625
Practice Address - Country:US
Practice Address - Phone:507-886-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA33589207Q00000X
MN52745207Q00000X
WI54634207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN148425700Medicaid
IA1215947Medicaid
MN148425700Medicaid
MN148425700Medicaid