Provider Demographics
NPI:1457406233
Name:JACK M. BERGSTEIN MD LLC
Entity Type:Organization
Organization Name:JACK M. BERGSTEIN MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:M
Authorized Official - Last Name:BERGSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:724-627-2860
Mailing Address - Street 1:1150 7TH ST
Mailing Address - Street 2:
Mailing Address - City:WAYNESBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15370-1660
Mailing Address - Country:US
Mailing Address - Phone:724-627-2760
Mailing Address - Fax:724-627-2692
Practice Address - Street 1:1150 7TH ST
Practice Address - Street 2:
Practice Address - City:WAYNESBURG
Practice Address - State:PA
Practice Address - Zip Code:15370-1660
Practice Address - Country:US
Practice Address - Phone:724-627-2760
Practice Address - Fax:724-627-2692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA075327VEXMedicare ID - Type Unspecified