Provider Demographics
NPI:1730472903
Name:BERGAMO PODIATRY PLLC
Entity Type:Organization
Organization Name:BERGAMO PODIATRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:BERGAMO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:845-343-6050
Mailing Address - Street 1:110 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-5119
Mailing Address - Country:US
Mailing Address - Phone:845-343-6050
Mailing Address - Fax:
Practice Address - Street 1:110 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-5119
Practice Address - Country:US
Practice Address - Phone:845-343-6050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-20
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNOO5115213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01515273Medicaid
NY1164420881OtherINDIVIDUAL NPI
NYP76801Medicare PIN
NY1164420881OtherINDIVIDUAL NPI