Healthcare Provider Details

I. General information

NPI: 1053392282
Provider Name (Legal Business Name): ROGER P BERMINGHAM M. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2005
Last Update Date: 06/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 PENNOCK PL
FORT COLLINS CO
80524-3257
US

IV. Provider business mailing address

1025 PENNOCK PL
FORT COLLINS CO
80524-3257
US

V. Phone/Fax

Practice location:
  • Phone: 970-495-8800
  • Fax: 970-495-8820
Mailing address:
  • Phone: 970-495-8800
  • Fax: 970-495-8820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number22982
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR.0022982
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: