1649277500 NPI number — MR. RUSTY BERGMAN D.O.

Table of content: MR. RUSTY BERGMAN D.O. (NPI 1649277500)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649277500 NPI number — MR. RUSTY BERGMAN D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERGMAN
Provider First Name:
RUSTY
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1649277500
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/16/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5675 ROE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROELAND PARK
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66205-2515
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-432-2080
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5675 ROE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROELAND PARK
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66205-2515
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-432-2080
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/06/2005

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: 207R00000X , with the licence number:  05-31668 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: 111070 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 245007000 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200304450A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7749362 . This is a "AETNA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 33625014 . This is a "BLUE SHIELD KANSAS CITY" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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