Provider Demographics
NPI:1679798326
Name:BERG, JAMES RALPH (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:RALPH
Last Name:BERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 S ROUTE 31
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050
Mailing Address - Country:US
Mailing Address - Phone:815-344-1400
Mailing Address - Fax:815-344-2173
Practice Address - Street 1:618 S IL ROUTE 31
Practice Address - Street 2:SUITE 2
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-8273
Practice Address - Country:US
Practice Address - Phone:815-344-1400
Practice Address - Fax:815-344-2173
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4900945OtherBLUE CROSS BLUE SHIELD
IL4900945OtherBLUE CROSS BLUE SHIELD
ILD14647Medicare UPIN