Provider Demographics
NPI:1801819826
Name:LANCE K BERGSTROM MD, PC
Entity Type:Organization
Organization Name:LANCE K BERGSTROM MD, PC
Other - Org Name:BERGSTROM EYE AND LASER CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:701-235-5200
Mailing Address - Street 1:2601 UNIVERSITY DR S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-6025
Mailing Address - Country:US
Mailing Address - Phone:701-235-5200
Mailing Address - Fax:701-237-0927
Practice Address - Street 1:2601 UNIVERSITY DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6025
Practice Address - Country:US
Practice Address - Phone:701-235-5200
Practice Address - Fax:701-237-0927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND545152W00000X
MN2581152W00000X
ND7230174400000X
MN38105174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND01068001OtherBLUE CROSS OF ND
MN33A70BEOtherCOMPREHENSIVE CARE SERVIC
MN33A70BEOtherBLUEPLUS OF MN
ND12698Medicaid
MN33A70BEOtherBLUE CROSS OF MN
ND01068001OtherBLUE CROSS FEDERAL
ND01068001OtherBLUE CROSS OF ND