Provider Demographics
NPI:1477753952
Name:BERGERON, EDWARD JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:JOSEPH
Last Name:BERGERON
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 1:1221 SIXTH ST STE 202
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2359
Mailing Address - Country:US
Mailing Address - Phone:231-935-5730
Mailing Address - Fax:231-935-5736
Practice Address - Street 1:1221 SIXTH ST STE 202
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2359
Practice Address - Country:US
Practice Address - Phone:231-935-5730
Practice Address - Fax:231-935-5736
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301086049208600000X, 208G00000X
CO390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program