Provider Demographics
NPI:1700018454
Name:BERGIN, COLLEEN JOAN (MBCHB)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:JOAN
Last Name:BERGIN
Suffix:
Gender:F
Credentials:MBCHB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 E FRONT AVE
Mailing Address - Street 2:SUITE 601
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2701
Mailing Address - Country:US
Mailing Address - Phone:866-400-4295
Mailing Address - Fax:208-763-3644
Practice Address - Street 1:601 E FRONT AVE
Practice Address - Street 2:SUITE 601
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2701
Practice Address - Country:US
Practice Address - Phone:866-400-4295
Practice Address - Fax:208-763-3644
Is Sole Proprietor?:No
Enumeration Date:2009-08-13
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-107812085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology