Provider Demographics
NPI:1629014105
Name:BERG, RUSSELL R (DC)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:R
Last Name:BERG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13835 N TATUM BLVD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-5581
Mailing Address - Country:US
Mailing Address - Phone:602-953-1900
Mailing Address - Fax:
Practice Address - Street 1:13835 N TATUM BLVD
Practice Address - Street 2:SUITE 3
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-5581
Practice Address - Country:US
Practice Address - Phone:602-953-1900
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1080111N00000X, 111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered111N00000XChiropractic ProvidersChiropractor
Not Answered111NS0005XChiropractic ProvidersChiropractorSports Physician