Provider Demographics
NPI:1891781258
Name:BERGMAN, STEPHEN K (CRNA ARN)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:K
Last Name:BERGMAN
Suffix:
Gender:M
Credentials:CRNA ARN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:IL
Mailing Address - Zip Code:62321-0160
Mailing Address - Country:US
Mailing Address - Phone:217-357-3131
Mailing Address - Fax:217-357-6564
Practice Address - Street 1:402 S ADAMS ST
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:IL
Practice Address - Zip Code:62321-1600
Practice Address - Country:US
Practice Address - Phone:217-357-3131
Practice Address - Fax:217-357-6564
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041149504163W00000X
IL209000387367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL963680Medicare ID - Type Unspecified