1053428573 NPI number — KURT BERGERON

Table of content: KURT BERGERON (NPI 1053428573)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053428573 NPI number — KURT BERGERON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERGERON
Provider First Name:
KURT
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1053428573
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/25/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
73 NEWTON RD
Provider Second Line Business Mailing Address:
STE 101
Provider Business Mailing Address City Name:
PLAISTOW
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03865-2424
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-388-7272
Provider Business Mailing Address Fax Number:
978-388-7373

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
282 STATE ROUTE 101
Provider Second Line Business Practice Location Address:
UNIT 11
Provider Business Practice Location Address City Name:
AMHERST
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03031-1706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-372-5125
Provider Business Practice Location Address Fax Number:
603-372-5126
Provider Enumeration Date:
08/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  2757 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000184301 . This is a "MEDICARE PTAN" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".




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