Provider Demographics
NPI:1780442103
Name:INTERNAL MEDICINE & AESTHETICS
Entity type:Organization
Organization Name:INTERNAL MEDICINE & AESTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-964-4100
Mailing Address - Street 1:PO BOX 443
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:IN
Mailing Address - Zip Code:47390-0443
Mailing Address - Country:US
Mailing Address - Phone:765-964-4100
Mailing Address - Fax:
Practice Address - Street 1:6505 CONSTITUTION BLVD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-1604
Practice Address - Country:US
Practice Address - Phone:269-599-8140
Practice Address - Fax:269-324-4329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty