Provider Demographics
NPI:1467850941
Name:MARTIN JAN BERGMAN
Entity Type:Organization
Organization Name:MARTIN JAN BERGMAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:JAN
Authorized Official - Last Name:BERGMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-521-1701
Mailing Address - Street 1:23 W CHESTER PIKE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:RIDLEY PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19078-1629
Mailing Address - Country:US
Mailing Address - Phone:610-521-1701
Mailing Address - Fax:610-521-9450
Practice Address - Street 1:23 W CHESTER PIKE
Practice Address - Street 2:SUITE 201
Practice Address - City:RIDLEY PARK
Practice Address - State:PA
Practice Address - Zip Code:19078-1629
Practice Address - Country:US
Practice Address - Phone:610-521-1701
Practice Address - Fax:610-521-9450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-15
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD 030099E207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
043725OtherPTAN
PA0010798830002Medicaid
B96734Medicare UPIN