Provider Demographics
NPI:1124097977
Name:BERG, RICHARD C JR (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:C
Last Name:BERG
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W WHITE RIVER BLVD
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-4988
Mailing Address - Country:US
Mailing Address - Phone:877-668-5621
Mailing Address - Fax:
Practice Address - Street 1:2600 GREENBUSH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2479
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:765-448-8027
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01056973A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN10923010OtherCAQH NUMBER
IN200402790Medicaid
IN000000248484OtherANTHEM PROVIDER NUMBER
IN467264OtherPHCS PID NUMBER
ING34750OtherMEDICARE UPIN NUMBER
IN200402790Medicaid
IN10923010OtherCAQH NUMBER
IN815450BBMedicare PIN
IN815490FFFMedicare PIN