Healthcare Provider Details

I. General information

NPI: 1972815348
Provider Name (Legal Business Name): FREDERICK IAN BERG D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2010
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 GULL RD
KALAMAZOO MI
49048-1609
US

IV. Provider business mailing address

3245 HEALTH DR STE 100
GRANGER IN
46530-1380
US

V. Phone/Fax

Practice location:
  • Phone: 269-633-2510
  • Fax: 269-633-2511
Mailing address:
  • Phone: 574-647-2713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberL1783455
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number5101018622
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: