Provider Demographics
NPI:1063493740
Name:BERGMAN, A. GABRIELLE (MD)
Entity Type:Individual
Prefix:
First Name:A. GABRIELLE
Middle Name:
Last Name:BERGMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 CADILLAC DRIVE
Mailing Address - Street 2:200
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027
Mailing Address - Country:US
Mailing Address - Phone:615-376-7360
Mailing Address - Fax:
Practice Address - Street 1:8 CADILLAC DR
Practice Address - Street 2:STE 200
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-5087
Practice Address - Country:US
Practice Address - Phone:615-376-7370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA454262085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807558000Medicaid
TN3002596Medicaid
OH000000391170OtherBCBS
AZ23482101Medicaid
CA00A454260Medicaid
CA00A454260OtherBCBS
P00146079OtherRXR MCR
OH2510143Medicaid
CA00A454260OtherBCBS
CA00A454261Medicare PIN
TN3002596Medicare PIN