Provider Demographics
NPI:1265495675
Name:BERGIN, JEFFREY KEITH (DC, DABCI)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:KEITH
Last Name:BERGIN
Suffix:
Gender:M
Credentials:DC, DABCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2629 SHERIDAN RD
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:ZION
Mailing Address - State:IL
Mailing Address - Zip Code:60099-2629
Mailing Address - Country:US
Mailing Address - Phone:847-872-8230
Mailing Address - Fax:847-872-8208
Practice Address - Street 1:2629 SHERIDAN RD
Practice Address - Street 2:SUITE 1A
Practice Address - City:ZION
Practice Address - State:IL
Practice Address - Zip Code:60099-2629
Practice Address - Country:US
Practice Address - Phone:847-872-8230
Practice Address - Fax:847-872-8208
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2008-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-004780111NI0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NI0900XChiropractic ProvidersChiropractorInternist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL743871001OtherMEDICARE PTAN
IL743871001OtherMEDICARE PTAN
ILT38417Medicare UPIN