Provider Demographics
NPI:1669400024
Name:BERGUM, RUSSELL ALAN (DO)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:ALAN
Last Name:BERGUM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2560 2ND ST SW STE 120
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55902-4363
Mailing Address - Country:US
Mailing Address - Phone:507-361-0400
Mailing Address - Fax:866-371-6710
Practice Address - Street 1:2560 2ND ST SW STE 120
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55902-4363
Practice Address - Country:US
Practice Address - Phone:507-361-0400
Practice Address - Fax:866-371-6710
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN42602207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN582436200Medicaid
MN582436200Medicaid
MN080014586Medicare PIN