Provider Demographics
NPI:1952414195
Name:BERGMAN ORTHOTIC & PROSTHEIC LLC
Entity Type:Organization
Organization Name:BERGMAN ORTHOTIC & PROSTHEIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:BERGMAN
Authorized Official - Suffix:
Authorized Official - Credentials:CO
Authorized Official - Phone:718-639-6771
Mailing Address - Street 1:5901 69TH ST
Mailing Address - Street 2:
Mailing Address - City:MASPETH
Mailing Address - State:NY
Mailing Address - Zip Code:11378-2946
Mailing Address - Country:US
Mailing Address - Phone:718-639-6771
Mailing Address - Fax:718-639-5184
Practice Address - Street 1:5901 69TH ST
Practice Address - Street 2:
Practice Address - City:MASPETH
Practice Address - State:NY
Practice Address - Zip Code:11378-2946
Practice Address - Country:US
Practice Address - Phone:718-639-6771
Practice Address - Fax:718-639-5184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01818611Medicaid
NY1193820001Medicare NSC
NY01818611Medicaid