1285891432 NPI number — RANDALL P BERGEN DPM PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285891432 NPI number — RANDALL P BERGEN DPM PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RANDALL P BERGEN DPM PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285891432
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
505 5TH ST
Provider Second Line Business Mailing Address:
SUITE 714
Provider Business Mailing Address City Name:
SIOUX CITY
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51101-1500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-255-3526
Provider Business Mailing Address Fax Number:
712-255-0298

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
505 5TH ST
Provider Second Line Business Practice Location Address:
SUITE 714
Provider Business Practice Location Address City Name:
SIOUX CITY
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51101-1500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-255-3526
Provider Business Practice Location Address Fax Number:
712-255-0298
Provider Enumeration Date:
05/16/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BERGEN
Authorized Official First Name:
RANDALL
Authorized Official Middle Name:
PAUL
Authorized Official Title or Position:
PRESIDENT PHYSICIAN
Authorized Official Telephone Number:
712-255-3526

Provider Taxonomy Codes

  • Taxonomy code: 261QP1100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0091108 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 480007118 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 09110 . This is a "WELLMARK BCBS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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