MEDICARE: MR. PHILIP WILLIAM BERGOLD 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	5058	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629073135
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PHILIP WILLIAM BERGOLD PT

Provider Business Mailing Address
First Line	:	PO BOX 370081
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53237-1181
Country	:	US
Telephone Number	:	414-940-7278
Fax Number	:	414-235-8448

Provider Business Practice Location Address
First Line	:	5889 RIVERSIDE DR
Second Line	:
City	:	GREENDALE
State	:	WI
Zip	:	53129-2817
Country	:	US
Telephone Number	:	414-940-7278
Fax Number	:	414-235-8448

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

Provider Enumeration Date	:	06/21/2005
Last Update Date	:	02/07/2016

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