Healthcare Provider Details

I. General information

NPI: 1801713979
Provider Name (Legal Business Name): MATTHEW ALEXANDER BERG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2026
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 W WYNDHAM HILL DR NE
GRAND RAPIDS MI
49505-7116
US

IV. Provider business mailing address

2121 W WYNDHAM HILL DR NE APT 302
GRAND RAPIDS MI
49505-6350
US

V. Phone/Fax

Practice location:
  • Phone: 248-568-8394
  • Fax:
Mailing address:
  • Phone: 248-568-8394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601003257
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: