Provider Demographics
NPI:1689629503
Name:BERGMAN COSMETIC SURGERY, PC
Entity Type:Organization
Organization Name:BERGMAN COSMETIC SURGERY, PC
Other - Org Name:DR. RONALD S BERGMAN DO PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:S
Authorized Official - Last Name:BERGMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:515-222-1111
Mailing Address - Street 1:PO BOX 71602
Mailing Address - Street 2:
Mailing Address - City:CLIVE
Mailing Address - State:IA
Mailing Address - Zip Code:50325-0602
Mailing Address - Country:US
Mailing Address - Phone:515-243-2057
Mailing Address - Fax:515-244-5570
Practice Address - Street 1:2000 GRAND AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50312-4920
Practice Address - Country:US
Practice Address - Phone:515-222-1111
Practice Address - Fax:515-244-9914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA208200000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0422980Medicaid
IA=========OtherIRS FEDERAL EIN
IA0422980Medicaid