Provider Demographics
NPI:1811908965
Name:BERGMAN, MARK (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BERGMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24701 EUCLID AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44117-1714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11100 EUCLID AVENUE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106
Practice Address - Country:US
Practice Address - Phone:440-205-5703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN102645207RH0003X
OH35090582207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH7795076OtherAETNA
OH000000541302OtherANTHEM
MN2444004OtherAMERICA'S PPO
OH2774654Medicaid
OH751099OtherBUCKEYE
MN006957000Medicaid
OH000000545329OtherANTHEM
WI34890000Medicaid
MN3600665OtherMEDICA
MNHP69898OtherHEALTHPARTNERS
OH421770OtherWELLCARE
MN490P0BEOtherBLUE CROSS BLUE SHIELD
OH000000226038OtherUNISON
MN133208OtherUCARE MN
OHP00459854OtherRAILROAD MEDICARE
OH000000226038OtherUNISON
OH000000541302OtherANTHEM
OH751099OtherBUCKEYE
MN490P0BEOtherBLUE CROSS BLUE SHIELD