Provider Demographics
NPI:1619953106
Name:BERGEON, BLAKE A (MD)
Entity Type:Individual
Prefix:MR
First Name:BLAKE
Middle Name:A
Last Name:BERGEON
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 1:555 W WACKERLY ST
Mailing Address - Street 2:#3825
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-4710
Mailing Address - Country:US
Mailing Address - Phone:989-631-9267
Mailing Address - Fax:989-839-0629
Practice Address - Street 1:555 W WACKERLY ST
Practice Address - Street 2:#3825
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-4710
Practice Address - Country:US
Practice Address - Phone:989-631-9267
Practice Address - Fax:989-839-0629
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301061418208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3383068Medicaid
G54165Medicare UPIN
MI3383068Medicaid