Provider Demographics
NPI:1295705382
Name:BERGESKI, BARBARA (PA)
Entity type:Individual
Prefix:
First Name:BARBARA
Middle Name:
Last Name:BERGESKI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17800 NEWBURGH RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-2700
Mailing Address - Country:US
Mailing Address - Phone:734-266-2780
Mailing Address - Fax:734-466-9615
Practice Address - Street 1:17800 NEWBURGH RD
Practice Address - Street 2:SUITE 103
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-2700
Practice Address - Country:US
Practice Address - Phone:734-464-9540
Practice Address - Fax:734-464-0438
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002728363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S77024Medicare UPIN