1700942125 NPI number — CAROL ELAINE BERGMANN AUD.,CCC-A

Table of content: CAROL ELAINE BERGMANN AUD.,CCC-A (NPI 1700942125)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700942125 NPI number — CAROL ELAINE BERGMANN AUD.,CCC-A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERGMANN
Provider First Name:
CAROL
Provider Middle Name:
ELAINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
AUD.,CCC-A
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:
1700942125
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/17/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15825 MANCHESTER RD
Provider Second Line Business Mailing Address:
SUITE 209
Provider Business Mailing Address City Name:
ELLISVILLE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63011-2263
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-391-9622
Provider Business Mailing Address Fax Number:
636-391-9236

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15825 MANCHESTER RD
Provider Second Line Business Practice Location Address:
SUITE 209
Provider Business Practice Location Address City Name:
ELLISVILLE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63011-2263
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-391-9622
Provider Business Practice Location Address Fax Number:
636-391-9236
Provider Enumeration Date:
12/29/2006

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: 237600000X , with the licence number:  00695 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 231H00000X , with the licence number: 01404 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 640004344 . This is a "RAILFROAD MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 431795961HEA . This is a "MERCY HEALTH PLAN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 46131 . This is a "HEALTHCARE USA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 407251 . This is a "HEALTHLINK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 7473310 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 141099800 . This is a "DEPARTMENT OF LABOR" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 431795961 . This is a "PLUMBERS & PIPEFITTERS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 4500105 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 126804 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 333890101 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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