Provider Demographics
NPI:1639710569
Name:AUDREY BERGESON MD PLLC
Entity Type:Organization
Organization Name:AUDREY BERGESON MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGESON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-903-3294
Mailing Address - Street 1:2102 E DIMPLE DELL RD
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84092-4827
Mailing Address - Country:US
Mailing Address - Phone:330-903-3294
Mailing Address - Fax:
Practice Address - Street 1:300 N HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:PRICE
Practice Address - State:UT
Practice Address - Zip Code:84501-4218
Practice Address - Country:US
Practice Address - Phone:330-903-3294
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-02
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty