Provider Demographics
NPI:1083675987
Name:BERGAN, CHAD M (MPT)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:M
Last Name:BERGAN
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 1ST ST NW
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-3121
Mailing Address - Country:US
Mailing Address - Phone:701-667-0745
Mailing Address - Fax:701-667-0707
Practice Address - Street 1:214 4TH ST NW
Practice Address - Street 2:
Practice Address - City:STEELE
Practice Address - State:ND
Practice Address - Zip Code:58482-7329
Practice Address - Country:US
Practice Address - Phone:701-202-3280
Practice Address - Fax:701-475-2022
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-30
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1329225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND030477097OtherWORK FORCE SAFETY
ND1475369Medicaid
ND650024893OtherPALMETTO GBA
ND030477097OtherTRIWEST
ND54130Medicaid