Provider Demographics
NPI:1831374446
Name:BERG, PHILLIP WILLIAM (DC)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:WILLIAM
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 1:2625 24TH AVE S
Mailing Address - Street 2:# B
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-6180
Mailing Address - Country:US
Mailing Address - Phone:763-421-2710
Mailing Address - Fax:
Practice Address - Street 1:11468 MARKETPLACE DR N
Practice Address - Street 2:SUITE 500
Practice Address - City:CHAMPLIN
Practice Address - State:MN
Practice Address - Zip Code:55316-3872
Practice Address - Country:US
Practice Address - Phone:763-421-2710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-02
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5047111N00000X
ND815111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor