Provider Demographics
NPI:1629070693
Name:BERGEN, BRENT D (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:D
Last Name:BERGEN
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:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-9007
Mailing Address - Country:US
Mailing Address - Phone:417-875-3462
Mailing Address - Fax:
Practice Address - Street 1:3800 S NATIONAL AVE STE 510
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5284
Practice Address - Country:US
Practice Address - Phone:417-875-3160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007001545207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204593909Medicaid
KY1069441OtherPASSPORT HEALTH
KY000000048062OtherANTHEM BCBS
290009315OtherRR MEDICARE
IN200096100AMedicaid
KY64319783Medicaid
KY000000048062OtherANTHEM BCBS