1609441609 NPI number — MRS. SHAMIR BERGERON APRN

Table of content: MRS. SHAMIR BERGERON APRN (NPI 1609441609)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609441609 NPI number — MRS. SHAMIR BERGERON APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERGERON
Provider First Name:
SHAMIR
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

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:
1609441609
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/24/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 40549
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELFAST
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04915-1256
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-207-9029
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2600 LAKE LUCIEN DR STE 112
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAITLAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32751-7233
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-266-4200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/21/2021

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: 363LF0000X , with the licence number:  11013119 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 117444500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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