Provider Demographics
NPI:1790225084
Name:BERGMAN, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BERGMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6327 S GRAND BLVD
Mailing Address - Street 2:APT 1G
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63111-2653
Mailing Address - Country:US
Mailing Address - Phone:314-333-2103
Mailing Address - Fax:
Practice Address - Street 1:6327 S GRAND BLVD
Practice Address - Street 2:APT 1G
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63111-2653
Practice Address - Country:US
Practice Address - Phone:314-333-2103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist