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General NPI Number Information
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NPI Number | 1972815348
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Entity Type | Individual
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Provider Name | FREDERICK IAN BERG D.O.
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Gender | Male
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Dates
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Enumeration Date | 07/13/2010
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Last Update Date | 10/14/2024
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Provider Practice Location Address
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Address Line | 42 N SAINT JOSEPH AVE STE 200
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City | NILES
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State | MI
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Zip | 49120-2203
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Country | US
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Telephone | 269-684-5447
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Fax |
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Provider Business Mailing Address
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Address Line | 42 N SAINT JOSEPH AVE STE 200
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City | NILES
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State | MI
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Zip | 49120-2203
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Country | US
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Telephone | 269-684-5447
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | L1783455
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | 5101018622
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License Number State | MI
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