Provider Demographics
NPI:1710053665
Name:BERGUM, MARY F (MD)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:F
Last Name:BERGUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3154 E 29TH AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99223-4852
Mailing Address - Country:US
Mailing Address - Phone:509-448-4870
Mailing Address - Fax:888-286-8401
Practice Address - Street 1:3154 E 29TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99223-4852
Practice Address - Country:US
Practice Address - Phone:509-448-4870
Practice Address - Fax:888-286-8401
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-24
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00042807207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8865268OtherPTAN
WAG8865268OtherPTAN