=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245496355
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TOD L BERG, M.D., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2008
-----------------------------------------------------
Last Update Date | 07/30/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1467 S HIGHWAY 40
-----------------------------------------------------
City | HEBER CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84032-3522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-654-6321
-----------------------------------------------------
Fax | 435-654-6364
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1467 S HIGHWAY 40
-----------------------------------------------------
City | HEBER CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84032-3522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-654-6321
-----------------------------------------------------
Fax | 435-654-6364
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. TOD L BERG
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 435-654-6321
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 2644771205
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------