1811908965 NPI number — MARK BERGMAN MD

Table of content: MARK BERGMAN MD (NPI 1811908965)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811908965 NPI number — MARK BERGMAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERGMAN
Provider First Name:
MARK
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1811908965
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/28/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24701 EUCLID AVE
Provider Second Line Business Mailing Address:
3RD FLOOR
Provider Business Mailing Address City Name:
EUCLID
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44117-1714
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11100 EUCLID AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-205-5703
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/11/2006

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: 207RH0003X , with the licence number:  102645 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RH0003X , with the licence number: 35090582 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7795076 . This is a "AETNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000541302 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2444004 . This is a "AMERICA'S PPO" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 2774654 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 751099 . This is a "BUCKEYE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 006957000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000545329 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 34890000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3600665 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP69898 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 421770 . This is a "WELLCARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 490P0BE . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000226038 . This is a "UNISON" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 133208 . This is a "UCARE MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: P00459854 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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