Provider Demographics
NPI:1801814108
Name:BERGOM, MICHAEL A (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:BERGOM
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1414 CROSS STREET
Mailing Address - Street 2:SUITE 330
Mailing Address - City:SHILOH
Mailing Address - State:IL
Mailing Address - Zip Code:62269-2998
Mailing Address - Country:US
Mailing Address - Phone:618-277-7400
Mailing Address - Fax:618-277-7422
Practice Address - Street 1:1414 CROSS STREET
Practice Address - Street 2:SUITE 330
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-2998
Practice Address - Country:US
Practice Address - Phone:618-277-7400
Practice Address - Fax:618-277-7422
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2024-03-20
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Provider Licenses
StateLicense IDTaxonomies
WI45795208600000X
IL036153202208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery