MEDICARE: MRS. AMY JANE BERGSTROM PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	QA00588200	NJ

General Provider Information

NPI Number	:	1265565204
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AMY JANE BERGSTROM PT

Provider Business Mailing Address
First Line	:	267 BIRCH HOLLOW DR
Second Line	:
City	:	BORDENTOWN
State	:	NJ
Zip	:	08505-4260
Country	:	US
Telephone Number	:	609-499-0371
Fax Number	:

Provider Business Practice Location Address
First Line	:	902 JACKSONVILLE RD
Second Line	:
City	:	BURLINGTON TOWNSHIP
State	:	NJ
Zip	:	08016-3814
Country	:	US
Telephone Number	:	609-239-3894
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/13/2007
Last Update Date	:	07/08/2007

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