Provider Demographics
NPI:1144894460
Name:BERG, MELINDA (PA-C)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:
Last Name:BERG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 NORTHRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:HILTON HEAD ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29926-3764
Mailing Address - Country:US
Mailing Address - Phone:843-681-6612
Mailing Address - Fax:
Practice Address - Street 1:15 NORTHRIDGE DR
Practice Address - Street 2:
Practice Address - City:HILTON HEAD ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29926-3764
Practice Address - Country:US
Practice Address - Phone:843-681-6612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-20
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4438363A00000X
FLPA9112298363A00000X
SCPA3980363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant