Provider Demographics
NPI:1619158375
Name:STEPHEN M. BERG, M.D.
Entity Type:Organization
Organization Name:STEPHEN M. BERG, M.D.
Other - Org Name:INTERNAL MEDICINE OF BLUE ASH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AUTUMN
Authorized Official - Middle Name:H
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-891-5900
Mailing Address - Street 1:9330 KENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45242-6810
Mailing Address - Country:US
Mailing Address - Phone:513-891-5900
Mailing Address - Fax:513-891-0762
Practice Address - Street 1:9330 KENWOOD RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45242-6810
Practice Address - Country:US
Practice Address - Phone:513-891-5900
Practice Address - Fax:513-891-0762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-21
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH47549207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0553726Medicaid
OH010014039OtherRAILROAD MEDICARE
OH9315621OtherMEDICARE GROUP NUMBER