NPIMap

Individual provider Active NPI

Ethan Patrick Berg, DO

  • Family Medicine Physician
  • Springfield, IL
National Provider Identifier
1831629401
Registry record updated Jun 15, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
125071205 Issued in IL
Practice address
520 N 4TH St
Springfield, IL 62702-5238
Phone
(217) 545-8000
Fax
(217) 757-8161
NPI assigned
Jun 15, 2017
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jun 15, 2017

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 125071205 IL Primary

Addresses

Primary practice location

520 N 4TH St
Springfield, IL 62702-5238

Mailing address

PO Box 19670
Springfield, IL 62794-9670

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20200513000959 IL Practitioner - Family Practice 9234409699 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
Other, 2017
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Board of Trustees of Southern Illinois University 139 clinicians

Practice addresses (Care Compare)

520 N 4TH St
Springfield, IL 62702-5238
Phone (217) 545-8000

Hospital & facility affiliations

  • Enhabit Home Health Home health agency, Springfield, IL, CCN 147708
  • Decatur Memorial Hospital Hospital, Decatur, IL, CCN 140135

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Osteopathy

State licenses

LicenseStateTypeSpecialty
125071205ILMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Board of Trustees of Southern Illinois University Current Accepting new patients
Board of Trustees of Southern Illinois University CurrentSince Jul 6, 2020 Accepting new patients
Board of Trustees of Southern Illinois University Family Medicine Current Accepting new patients
Board of Trustees of Southern Illinois University CurrentSince Jul 6, 2020 Accepting new patients

Locations

520 N 4th St
Springfield, IL 62702
Phone (217) 757-8100

Interoperability endpoints

  • Direct secure messaging: ethanberg@siusm.allscriptsdirect.net

Organizations & group practices 20

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

View all 20

Hospital & facility affiliations 2

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1497484800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1497484800000",
    "number": "1831629401",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 19670",
            "city": "SPRINGFIELD",
            "state": "IL",
            "postal_code": "627949670"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "520 N 4TH ST",
            "city": "SPRINGFIELD",
            "state": "IL",
            "postal_code": "627025238",
            "telephone_number": "217-545-8000",
            "fax_number": "217-757-8161"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BERG",
        "first_name": "ETHAN",
        "middle_name": "PATRICK",
        "name_prefix": "Dr.",
        "credential": "DO",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2017-06-15",
        "last_updated": "2017-06-15",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "IL",
            "license": "125071205",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Springfield, IL

Sources for this page

Verify at the official NPI Registry.