Provider Demographics
NPI:1790135119
Name:BERGUM, MEGAN DANIELLE (DEM)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:DANIELLE
Last Name:BERGUM
Suffix:
Gender:F
Credentials:DEM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10468 RAVENSWOOD RD
Mailing Address - Street 2:
Mailing Address - City:RAVENSWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26164-6145
Mailing Address - Country:US
Mailing Address - Phone:304-482-4729
Mailing Address - Fax:
Practice Address - Street 1:10468 RAVENSWOOD RD
Practice Address - Street 2:
Practice Address - City:RAVENSWOOD
Practice Address - State:WV
Practice Address - Zip Code:26164-6145
Practice Address - Country:US
Practice Address - Phone:304-482-4729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-16
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No174N00000XOther Service ProvidersLactation Consultant, Non-RN
No374J00000XNursing Service Related ProvidersDoula