Provider Demographics
NPI:1982100988
Name:BERGIN, EDWARD PATRICK (MD, MS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:PATRICK
Last Name:BERGIN
Suffix:
Gender:M
Credentials:MD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 S BURMA AVE
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82716-3426
Mailing Address - Country:US
Mailing Address - Phone:307-688-1000
Mailing Address - Fax:
Practice Address - Street 1:501 S BURMA AVE
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-3426
Practice Address - Country:US
Practice Address - Phone:307-688-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-30
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WYTL7310207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program