Provider Demographics
NPI:1033767512
Name:BERGMAN, LOUIS WILLIAM
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:WILLIAM
Last Name:BERGMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2623 W 20TH ST
Mailing Address - Street 2:
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-9478
Mailing Address - Country:US
Mailing Address - Phone:906-203-4589
Mailing Address - Fax:
Practice Address - Street 1:3763 75 BUSINESS SPUR
Practice Address - Street 2:
Practice Address - City:SAULT STE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783
Practice Address - Country:US
Practice Address - Phone:906-632-0582
Practice Address - Fax:906-632-0584
Is Sole Proprietor?:No
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302121230183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302121230OtherOTHER