Provider Demographics
NPI:1124001094
Name:BERGHOFER, STEPHEN HENRY (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:HENRY
Last Name:BERGHOFER
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 1:10330 N MERIDIAN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46290-1024
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:112 S HARRISON ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:IN
Practice Address - Zip Code:46001-2067
Practice Address - Country:US
Practice Address - Phone:765-724-7627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2008-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01043612A207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200062200Medicaid
INP00616368OtherRAILROAD INDIVIDUAL
INDC3600OtherRAILROAD GROUP
IN940240WWMedicare PIN
IN220800EMedicare PIN
INP00616368OtherRAILROAD INDIVIDUAL
IN200062200Medicaid