Provider Demographics
NPI:1578509733
Name:BERGSTROM, LANCE K (MD)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:K
Last Name:BERGSTROM
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 1:2601 UNIVERSITY DR S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-6025
Mailing Address - Country:US
Mailing Address - Phone:701-235-5200
Mailing Address - Fax:701-237-0927
Practice Address - Street 1:2601 UNIVERSITY DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6025
Practice Address - Country:US
Practice Address - Phone:701-235-5200
Practice Address - Fax:701-237-0927
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND7230174400000X
MN38105174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND18672Medicaid
MN33A71BEOtherMN BCBS
MN080024400Medicaid
ND01068001OtherBCBS OF ND
ND12698Medicaid
MN33A70BEOtherMN BCBS
ND236454OtherND BCBS
ND18672Medicaid
NDN23645Medicare ID - Type Unspecified
MNG11949Medicare UPIN
NDG11949Medicare UPIN
ND12698Medicaid
MN080024400Medicaid