Provider Demographics
NPI:1326056722
Name:BERGMAN, JASON B (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:B
Last Name:BERGMAN
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 1:19550 E 39TH ST S STE 335
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64057-2311
Mailing Address - Country:US
Mailing Address - Phone:816-350-0005
Mailing Address - Fax:816-350-0015
Practice Address - Street 1:19550 E 39TH ST S STE 335
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057-2311
Practice Address - Country:US
Practice Address - Phone:816-350-0005
Practice Address - Fax:816-350-0015
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004016407207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200418930AMedicaid
MO201468105Medicaid
MOP00373752OtherRAILROAD
MOP00373752OtherRAILROAD
MOP09E800Medicare PIN
MO1326056722Medicaid