Provider Demographics
NPI:1518960715
Name:BERGESON, RACHEL (MD)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:
Last Name:BERGESON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 SCHOONER CV
Mailing Address - Street 2:
Mailing Address - City:SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-3951
Mailing Address - Country:US
Mailing Address - Phone:631-689-9346
Mailing Address - Fax:631-632-6936
Practice Address - Street 1:1 STADIUM RD
Practice Address - Street 2:
Practice Address - City:STONYBROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-3191
Practice Address - Country:US
Practice Address - Phone:631-632-6740
Practice Address - Fax:631-632-6936
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY1463092080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYD46595Medicare UPIN