Provider Demographics
NPI:1285891432
Name:RANDALL P BERGEN DPM PC
Entity type:Organization
Organization Name:RANDALL P BERGEN DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:BERGEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:712-255-3526
Mailing Address - Street 1:505 5TH ST
Mailing Address - Street 2:SUITE 714
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51101-1500
Mailing Address - Country:US
Mailing Address - Phone:712-255-3526
Mailing Address - Fax:712-255-0298
Practice Address - Street 1:505 5TH ST
Practice Address - Street 2:SUITE 714
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51101-1500
Practice Address - Country:US
Practice Address - Phone:712-255-3526
Practice Address - Fax:712-255-0298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0091108Medicaid
IA480007118OtherRAILROAD MEDICARE
IA09110OtherWELLMARK BCBS
IAT00681Medicare UPIN
IA0091108Medicaid
IA480007118OtherRAILROAD MEDICARE