Provider Demographics
NPI:1285612325
Name:BERG, JOHN C (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:BERG
Suffix:
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 1:523 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-3054
Mailing Address - Country:US
Mailing Address - Phone:218-829-2861
Mailing Address - Fax:
Practice Address - Street 1:2024 S 6TH ST.
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-3054
Practice Address - Country:US
Practice Address - Phone:218-828-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN30400207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN946800500Medicaid
MN946800500Medicaid
MNF31412Medicare UPIN