Provider Demographics
NPI:1992859805
Name:BERGMAN, STUART M (MD)
Entity Type:Individual
Prefix:DR
First Name:STUART
Middle Name:M
Last Name:BERGMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:775 POLE LINE RD W STE 301
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5823
Practice Address - Country:US
Practice Address - Phone:208-814-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD465614208800000X
FLME100410208800000X
IDM-15122208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL47450OtherBCBS OF FL
FLP01195011OtherRAILROAD MCR
FLP110118OtherFREEDOM HEALTH
10381145OtherCAQH
FL325061OtherAVMED
FL5248030OtherAETNA
FL1192907OtherWELLCARE
FL10H686OtherHEALTHY KIDS
VA7595816Medicaid
NC2292290 AOtherPIEDMONT STONE CENTER PHY
FL000256000Medicaid
FL8533707OtherCIGNA
FLB09581Medicare UPIN
VA7595816Medicaid
FLP00645720Medicare PIN
FL47450OtherBCBS OF FL
FL000256000Medicaid