MEDICARE: LISA A BERGERON 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	208000000X	Pediatrics Physician	35065206	OH
2	208000000X	Pediatrics Physician	01043876A	IN

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
2	000000602350	OTHER	IN	ANTHEM

General Provider Information

NPI Number	:	1801890355
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA A BERGERON M.D.

Provider Business Mailing Address
First Line	:	11109 PARKVIEW PLAZA DR # 117
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-1701
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11115 PARKVIEW PLAZA DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-1701
Country	:	US
Telephone Number	:	260-266-5400
Fax Number	:	260-266-5405

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

Provider Enumeration Date	:	06/10/2005
Last Update Date	:	12/20/2022

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