Provider Demographics
NPI:1710977004
Name:BERGMAN, MARTIN JAN (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:JAN
Last Name:BERGMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 W CHESTER PIKE STE 201
Mailing Address - Street 2:
Mailing Address - City:RIDLEY PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19078-1629
Mailing Address - Country:US
Mailing Address - Phone:610-521-1701
Mailing Address - Fax:610-521-9450
Practice Address - Street 1:23 W CHESTER PIKE STE 201
Practice Address - Street 2:
Practice Address - City:RIDLEY PARK
Practice Address - State:PA
Practice Address - Zip Code:19078-1629
Practice Address - Country:US
Practice Address - Phone:610-521-1701
Practice Address - Fax:610-521-9450
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-27
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD030099E207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1079883Medicaid
PA1079883Medicaid
B96734Medicare UPIN