Healthcare Provider Details

I. General information

NPI: 1619284577
Provider Name (Legal Business Name): KYLE STEVEN BERGESON DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2010
Last Update Date: 09/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3654 W ANTHEM WAY STE B102
ANTHEM AZ
85086-0455
US

IV. Provider business mailing address

17204 N 46TH ST
PHOENIX AZ
85032
US

V. Phone/Fax

Practice location:
  • Phone: 623-551-9706
  • Fax:
Mailing address:
  • Phone: 605-359-5807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number9049
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: