Provider Demographics
NPI:1134488364
Name:BERGERON, MARC
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:BERGERON
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 1:66 WOLF HILL RD
Mailing Address - Street 2:
Mailing Address - City:HILLSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:12529-5421
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:66 WOLF HILL RD
Practice Address - Street 2:
Practice Address - City:HILLSDALE
Practice Address - State:NY
Practice Address - Zip Code:12529-5421
Practice Address - Country:US
Practice Address - Phone:518-672-5519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-08
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY223611-1207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery