Provider Demographics
NPI:1043253339
Name:BERG, EDWARD D
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:D
Last Name:BERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7201 W SAGINAW HWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-1131
Mailing Address - Country:US
Mailing Address - Phone:517-321-6801
Mailing Address - Fax:
Practice Address - Street 1:7201 W SAGINAW HWY
Practice Address - Street 2:SUITE 300
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-1131
Practice Address - Country:US
Practice Address - Phone:517-321-6801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIEB006059207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI200000002582OtherPHPMM
MI0452329554OtherBLUE CROSS BLUE SHIELD
MI1063159Medicaid
MI0452329554OtherBLUE CROSS BLUE SHIELD
MI200000002582OtherPHPMM
E37538Medicare UPIN