Provider Demographics
NPI:1972815348
Name:BERG, FREDERICK IAN (DO)
Entity type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:IAN
Last Name:BERG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 N SAINT JOSEPH AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-2203
Mailing Address - Country:US
Mailing Address - Phone:269-684-5447
Mailing Address - Fax:
Practice Address - Street 1:42 N SAINT JOSEPH AVE STE 200
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-2203
Practice Address - Country:US
Practice Address - Phone:269-684-5447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-13
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL1783455208800000X
MI5101018622208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology