Healthcare Provider Details

I. General information

NPI: 1801883558
Provider Name (Legal Business Name): RICHARD A. BERG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2005
Last Update Date: 02/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22201 MOROSS RD SUITE 155
DETROIT MI
48236-2169
US

IV. Provider business mailing address

45640 SCHOENHERR RD SUITE B
SHELBY TOWNSHIP MI
48315-6033
US

V. Phone/Fax

Practice location:
  • Phone: 586-247-4300
  • Fax:
Mailing address:
  • Phone: 586-247-4300
  • Fax: 586-532-6496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number4301041478
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: