Healthcare Provider Details

I. General information

NPI: 1720507767
Provider Name (Legal Business Name): MALLORY MARIE BERG FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 W 119TH ST
PALOS PARK IL
60464-3041
US

IV. Provider business mailing address

10129 BUELL CT
OAK LAWN IL
60453-3802
US

V. Phone/Fax

Practice location:
  • Phone: 708-361-3300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number209.016365
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: