Provider Demographics
NPI: | 1912902784 |
---|---|
Name: | BERGMAN, GREGORY ALAN (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | GREGORY |
Middle Name: | ALAN |
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: | 1002 S KNOXVILLE AVE |
Mailing Address - Street 2: | GRAND LAKE PHYSICIAN PRACTICES |
Mailing Address - City: | SAINT MARYS |
Mailing Address - State: | OH |
Mailing Address - Zip Code: | 45885-2607 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 419-394-3387 |
Mailing Address - Fax: | 419-628-9501 |
Practice Address - Street 1: | 4463 STATE ROUTE 66N |
Practice Address - Street 2: | |
Practice Address - City: | MINSTER |
Practice Address - State: | OH |
Practice Address - Zip Code: | 45865-8727 |
Practice Address - Country: | US |
Practice Address - Phone: | 419-394-3387 |
Practice Address - Fax: | 419-628-9501 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-06-16 |
Last Update Date: | 2011-02-03 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OH | 047703 | 207Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OH | 0537502 | Medicaid | |
OH | 1104024546 | Other | ORGANIZATIONAL NPI |
OH | 2268237 | Other | MEDICAID LEGACY |
OH | 9934723 | Other | MEDICARE PTAN |
OH | BE0553544 | Medicare PIN |