Provider Demographics
NPI:1801883558
Name:BERG, RICHARD A (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:A
Last Name:BERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:45640 SCHOENHERR RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-6033
Mailing Address - Country:US
Mailing Address - Phone:586-247-4300
Mailing Address - Fax:586-532-6496
Practice Address - Street 1:22201 MOROSS RD
Practice Address - Street 2:SUITE 155
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2169
Practice Address - Country:US
Practice Address - Phone:586-247-4300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-28
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010414782086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1846920Medicaid
020H21281OtherBCBSM
B43041Medicare UPIN
B43041Medicare UPIN