Provider Demographics
NPI:1376507756
Name:BERGQUIST, ERICK J (MD)
Entity Type:Individual
Prefix:DR
First Name:ERICK
Middle Name:J
Last Name:BERGQUIST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:640 KOLTER DR
Mailing Address - Street 2:
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-3570
Mailing Address - Country:US
Mailing Address - Phone:724-357-7196
Mailing Address - Fax:724-357-7279
Practice Address - Street 1:121 W 2ND AVE
Practice Address - Street 2:
Practice Address - City:LATROBE
Practice Address - State:PA
Practice Address - Zip Code:15650-1068
Practice Address - Country:US
Practice Address - Phone:412-920-5860
Practice Address - Fax:412-920-5861
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD015265E207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0007280820001Medicaid
PA0007280820001Medicaid
PAB33506Medicare UPIN