Provider Demographics
NPI:1023383700
Name:BERGSTEIN, JERRY MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:MICHAEL
Last Name:BERGSTEIN
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 1:8905 SOURWOOD CT
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-1544
Mailing Address - Country:US
Mailing Address - Phone:317-872-4459
Mailing Address - Fax:317-872-4459
Practice Address - Street 1:8905 SOURWOOD CT
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1544
Practice Address - Country:US
Practice Address - Phone:317-872-4459
Practice Address - Fax:317-872-4459
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-14
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01027479A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INB28258Medicare UPIN