1841387735 NPI number — LINDA BERGIN GOFORTH PA-C

Table of content: LINDA BERGIN GOFORTH PA-C (NPI 1841387735)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841387735 NPI number — LINDA BERGIN GOFORTH PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOFORTH
Provider First Name:
LINDA
Provider Middle Name:
BERGIN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1841387735
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/04/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2001 MANATEE AVENUE EAST,
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
BRADENTON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34208
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-803-8395
Provider Business Mailing Address Fax Number:
941-803-8158

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2001 MANATEE AVE E
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
BRADENTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34208-1620
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-803-8395
Provider Business Practice Location Address Fax Number:
941-803-8158
Provider Enumeration Date:
10/10/2006

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: 363AM0700X , with the licence number:  102514 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: PA9106347 , 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: MB0350710 . This is a "CONTROLLED SUBSTANCE REGI" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com