Provider Demographics
NPI:1629073135
Name:BERGOLD, PHILIP WILLIAM (PT)
Entity Type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:WILLIAM
Last Name:BERGOLD
Suffix:
Gender:M
Credentials:PT
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 370081
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53237-1181
Mailing Address - Country:US
Mailing Address - Phone:414-940-7278
Mailing Address - Fax:414-235-8448
Practice Address - Street 1:5889 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:GREENDALE
Practice Address - State:WI
Practice Address - Zip Code:53129-2817
Practice Address - Country:US
Practice Address - Phone:414-940-7278
Practice Address - Fax:414-235-8448
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2016-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5058225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40377300Medicaid
WI3165001Medicare PIN