MEDICARE: DR. LARS BERGESON M.D.

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	207Q00000X	Family Medicine Physician	170371-1205	UT

General Provider Information

NPI Number	:	1497721195
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LARS BERGESON M.D.

Provider Business Mailing Address
First Line	:	PO BOX 609
Second Line	:
City	:	PROVIDENCE
State	:	UT
Zip	:	84332-0609
Country	:	US
Telephone Number	:	435-752-0330
Fax Number	:	435-755-0922

Provider Business Practice Location Address
First Line	:	382 W 280 N
Second Line	:
City	:	PROVIDENCE
State	:	UT
Zip	:	84332-9707
Country	:	US
Telephone Number	:	435-752-0330
Fax Number	:	435-755-0922

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

Provider Enumeration Date	:	02/23/2006
Last Update Date	:	11/09/2009

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