Provider Demographics
NPI:1245496355
Name:TOD L BERG, M.D., P.C.
Entity type:Organization
Organization Name:TOD L BERG, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TOD
Authorized Official - Middle Name:L
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-654-6321
Mailing Address - Street 1:1467 S HIGHWAY 40
Mailing Address - Street 2:
Mailing Address - City:HEBER CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84032-3522
Mailing Address - Country:US
Mailing Address - Phone:435-654-6321
Mailing Address - Fax:435-654-6364
Practice Address - Street 1:1467 S HIGHWAY 40
Practice Address - Street 2:
Practice Address - City:HEBER CITY
Practice Address - State:UT
Practice Address - Zip Code:84032-3522
Practice Address - Country:US
Practice Address - Phone:435-654-6321
Practice Address - Fax:435-654-6364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-29
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2644771205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1245496355OtherORGANIZATIONAL NPI
UT529061882001Medicaid
UT1497713648OtherINDIVIDUAL NPI
UT1245496355OtherORGANIZATIONAL NPI
UT529061882001Medicaid