1801819826 NPI number — LANCE K BERGSTROM MD, PC

Table of content: (NPI 1801819826)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801819826 NPI number — LANCE K BERGSTROM MD, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LANCE K BERGSTROM MD, 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:
BERGSTROM EYE AND LASER CLINIC
Provider Other Organization Name Type Code:
3
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:
1801819826
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/22/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2601 UNIVERSITY DR S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARGO
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58103-6025
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-235-5200
Provider Business Mailing Address Fax Number:
701-237-0927

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2601 UNIVERSITY DR S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58103-6025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-235-5200
Provider Business Practice Location Address Fax Number:
701-237-0927
Provider Enumeration Date:
07/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BERGSTROM
Authorized Official First Name:
LANCE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
701-235-5200

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  545 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 2581 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174400000X , with the licence number: 7230 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 174400000X , with the licence number: 38105 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 01068001 . This is a "BLUE CROSS OF ND" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 33A70BE . This is a "COMPREHENSIVE CARE SERVIC" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 33A70BE . This is a "BLUEPLUS OF MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 12698 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 33A70BE . This is a "BLUE CROSS OF MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 01068001 . This is a "BLUE CROSS FEDERAL" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".




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