Provider Demographics
NPI:1609021104
Name:BERGMAN, STEPHEN RUSSELL (DO)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:RUSSELL
Last Name:BERGMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 BRITTAIN DR
Mailing Address - Street 2:
Mailing Address - City:HARROGATE
Mailing Address - State:TN
Mailing Address - Zip Code:37752-7018
Mailing Address - Country:US
Mailing Address - Phone:720-838-6700
Mailing Address - Fax:
Practice Address - Street 1:6965 CUMBERLAND GAP PKWY
Practice Address - Street 2:
Practice Address - City:HARROGATE
Practice Address - State:TN
Practice Address - Zip Code:37752-8245
Practice Address - Country:US
Practice Address - Phone:423-869-6249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-25
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007018743204D00000X, 208D00000X
ARE-12201208D00000X, 204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO108400081OtherPTAN
MO1609021104Medicaid