Basic Information
| Provider Information | |||||||||
| NPI: | 1962438960 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERG | ||||||||
| FirstName: | KIMBERLY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8003 | ||||||||
| Address2: | |||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549128003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209963298 | ||||||||
| FaxNumber: | 9207385787 | ||||||||
| Practice Location | |||||||||
| Address1: | 1380 TULLAR RD | ||||||||
| Address2: | |||||||||
| City: | NEENAH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549564440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207273480 | ||||||||
| FaxNumber: | 9207273490 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 03/04/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 39011 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 32571300 | 05 | WI | MEDICAID |