Provider Demographics
NPI:1134365620
Name:PENNSYLVANIA INTERNAL MEDICINE & GERIATRICS PC
Entity type:Organization
Organization Name:PENNSYLVANIA INTERNAL MEDICINE & GERIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:M
Authorized Official - Last Name:BERGMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-637-0102
Mailing Address - Street 1:9501 HILSPACH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-3918
Mailing Address - Country:US
Mailing Address - Phone:215-637-0102
Mailing Address - Fax:215-281-0464
Practice Address - Street 1:9503 STATE RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-3034
Practice Address - Country:US
Practice Address - Phone:215-637-0102
Practice Address - Fax:215-281-0464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-05
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD012582E207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000592556Medicaid
PA835253OtherAETNA INSURANCE
PA0053907001OtherKEYSTONE HEALTH PLAN EAST
PA110026458OtherPALMETTO GBA MEDICARE RAILROAD
PA129328701OtherUNITED HEALTHCARE
PA035806OtherHIGHMARK MEDICARE SERVICES
PA19361OtherBRAVO HEALTHCRE
PA000592556Medicaid