Provider Demographics
NPI:1770526840
Name:BERG, RICHARD (DO)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:BERG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 E FRONT ST
Mailing Address - Street 2:
Mailing Address - City:HANCOCK
Mailing Address - State:NY
Mailing Address - Zip Code:13783-1242
Mailing Address - Country:US
Mailing Address - Phone:607-637-5700
Mailing Address - Fax:607-637-5703
Practice Address - Street 1:116 E FRONT ST
Practice Address - Street 2:
Practice Address - City:HANCOCK
Practice Address - State:NY
Practice Address - Zip Code:13783-1242
Practice Address - Country:US
Practice Address - Phone:607-637-5700
Practice Address - Fax:607-637-5703
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY238543207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02731639Medicaid
NY02731639Medicaid