Provider Demographics
NPI:1164647434
Name:JOAN L BERGSTROM, MD PA
Entity Type:Organization
Organization Name:JOAN L BERGSTROM, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:BERGSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-277-9415
Mailing Address - Street 1:1001 N WALDROP DR
Mailing Address - Street 2:SUITE 505
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76012-4705
Mailing Address - Country:US
Mailing Address - Phone:817-277-9415
Mailing Address - Fax:817-277-0360
Practice Address - Street 1:1001 N WALDROP DR
Practice Address - Street 2:SUITE 505
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76012-4705
Practice Address - Country:US
Practice Address - Phone:817-277-9415
Practice Address - Fax:817-277-0360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8579261QM1300X
TXL0505261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1245214550OtherDR. PEPPLERS NPI
TX1396727814OtherDR. BERGSTROMS NPI
TX8167MIMedicare ID - Type UnspecifiedDR PEPPLERS MEDICARE
TX1245214550OtherDR. PEPPLERS NPI
TXH26605Medicare UPIN
TX1396727814OtherDR. BERGSTROMS NPI
TX8167MOMedicare ID - Type UnspecifiedDR. BERGSTROMS MEDICARE