MEDICARE: SYDNEY SHEA VON BERGEN ATS

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	2255A2300X	Athletic Trainer

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	22	OTHER	MT	RESPIRATORY, REHABILITATIVE & RESTORATIVE SERVICE PROVIDERS

General Provider Information

NPI Number	:	1578451373
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SYDNEY SHEA VON BERGEN ATS

Provider Business Mailing Address
First Line	:	512 PATTEE CANYON DR
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59803-1621
Country	:	US
Telephone Number	:	406-366-5984
Fax Number	:

Provider Business Practice Location Address
First Line	:	512 PATTEE CANYON DR
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59803-1621
Country	:	US
Telephone Number	:	406-366-5984
Fax Number	:

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

Provider Enumeration Date	:	06/27/2025
Last Update Date	:	06/27/2025

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