Provider Demographics
NPI:1861460107
Name:BERGEON, TAMMY THOMPSON (PT ATC)
Entity Type:Individual
Prefix:MS
First Name:TAMMY
Middle Name:THOMPSON
Last Name:BERGEON
Suffix:
Gender:F
Credentials:PT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4812 FOSTER RD
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48642-3230
Mailing Address - Country:US
Mailing Address - Phone:989-430-7187
Mailing Address - Fax:
Practice Address - Street 1:4812 FOSTER RD
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48642-3230
Practice Address - Country:US
Practice Address - Phone:989-430-7187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-11
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501008750225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501008750OtherDEPT OF COMM HEALTH
650E611120OtherBCBS
MI650E610810OtherBCBS