Provider Demographics
NPI:1871761858
Name:BERGMAN, STEPHEN ERIC (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:ERIC
Last Name:BERGMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:S.
Other - Middle Name:ERIC
Other - Last Name:BERGMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:MEDICAL TOWERS N BLDG 1169
Mailing Address - Street 2:STE 3412
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-2026
Mailing Address - Country:US
Mailing Address - Phone:502-456-6001
Mailing Address - Fax:
Practice Address - Street 1:1169 EASTERN PARKWAY
Practice Address - Street 2:MEDICAL ARTS BUILDING STE 3412
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217
Practice Address - Country:US
Practice Address - Phone:502-456-6001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-13
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY19335207Y00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64193352Medicaid
KY64193352Medicaid