Provider Demographics
NPI:1154460152
Name:BERGESON, RYAN (MD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:BERGESON
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 1:1520 LEANDER RD STE 100
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-8829
Mailing Address - Country:US
Mailing Address - Phone:512-942-2499
Mailing Address - Fax:512-943-0001
Practice Address - Street 1:1520 LEANDER RD STE 101
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-8842
Practice Address - Country:US
Practice Address - Phone:512-942-2499
Practice Address - Fax:512-943-0001
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2003-0222207X00000X
KY41610207XS0117X
TXN2403207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000577128OtherANTHEM (SPINE INSTITUTE)
KY000000586305OtherANTHEM (UNIV ORTHO ASSOC)
TX219591906Medicaid
KY0605950Medicare PIN