Provider Demographics
NPI:1740864313
Name:BERGESON, KEIFER (DO)
Entity type:Individual
Prefix:DR
First Name:KEIFER
Middle Name:
Last Name:BERGESON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1041 DUKELANA LN
Mailing Address - Street 2:
Mailing Address - City:NEWCASTLE
Mailing Address - State:CA
Mailing Address - Zip Code:95658-9587
Mailing Address - Country:US
Mailing Address - Phone:916-276-6894
Mailing Address - Fax:
Practice Address - Street 1:1 GENESYS PKWY
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-8065
Practice Address - Country:US
Practice Address - Phone:916-276-6894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-10
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5151015096207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery