Provider Demographics
NPI:1285950451
Name:BERG, MELINDA BETH
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:BETH
Last Name:BERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELINDA
Other - Middle Name:BETH
Other - Last Name:HALLSTROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 RIVARD ST
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:WI
Practice Address - Zip Code:54025-7382
Practice Address - Country:US
Practice Address - Phone:715-247-2060
Practice Address - Fax:715-247-2070
Is Sole Proprietor?:No
Enumeration Date:2010-04-13
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN54048207Q00000X
WI60709-21207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine