=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619158375
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STEPHEN M. BERG, M.D.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2007
-----------------------------------------------------
Last Update Date | 09/18/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9330 KENWOOD RD
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45242-6810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-891-5900
-----------------------------------------------------
Fax | 513-891-0762
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9330 KENWOOD RD
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45242-6810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-891-5900
-----------------------------------------------------
Fax | 513-891-0762
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | MRS. AUTUMN H THOMAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 513-891-5900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 47549
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------