Provider Demographics
NPI:1942299730
Name:BERGERSEN, LISA (MD MPH)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:BERGERSEN
Suffix:
Gender:F
Credentials:MD MPH
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 9135
Mailing Address - Street 2:ATT:SHARON SILVA
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-9135
Mailing Address - Country:US
Mailing Address - Phone:603-890-4404
Mailing Address - Fax:603-893-8886
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:617-335-7893
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2020-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA160372207RI0011X, 208000000X, 2080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2039290Medicaid
MA28244OtherBMC HEALTHNET
MAJ27337OtherHMO BLUE
MAJ27337OtherBCBS MA
MA468809OtherTUFTS HEALTH PLAN
MA96969201OtherNETWORK HEALTH
MA2501928OtherUNITED HEALTHCARE MA
MAJ27337OtherBLUE CARE ELECT
RILB54040Medicaid
I04212Medicare UPIN
RILB54040Medicaid