Provider Demographics
NPI:1669443032
Name:BERGMAN, KENNETH S (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:S
Last Name:BERGMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:314 MLK JR WAY
Mailing Address - Street 2:STE 11
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405
Mailing Address - Country:US
Mailing Address - Phone:253-627-6172
Mailing Address - Fax:253-627-8792
Practice Address - Street 1:11511 CANTERWOOD BLVD NW
Practice Address - Street 2:SUITE 50
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98332-5813
Practice Address - Country:US
Practice Address - Phone:253-851-5155
Practice Address - Fax:253-851-5367
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2012-08-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WAMD000301002085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8293987Medicaid
WA8293987Medicaid