Provider Demographics
NPI:1336335884
Name:LARS BERGESON, MD, PC
Entity Type:Organization
Organization Name:LARS BERGESON, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LARS
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGESON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-752-0330
Mailing Address - Street 1:PO BOX 609
Mailing Address - Street 2:382 N 280 W
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-0609
Mailing Address - Country:US
Mailing Address - Phone:435-752-0330
Mailing Address - Fax:435-755-0922
Practice Address - Street 1:382 N 280 W
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-0609
Practice Address - Country:US
Practice Address - Phone:435-752-0330
Practice Address - Fax:435-755-0922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT170371-1205261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000011835Medicare PIN
UTC63887Medicare UPIN