Healthcare Provider Details

I. General information

NPI: 1235752866
Provider Name (Legal Business Name): PHILIP JACOB BERGEN JR. PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2020
Last Update Date: 10/30/2025
Certification Date: 10/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 OLD NEW MILFORD RD STE 3E
BROOKFIELD CT
06804-2414
US

IV. Provider business mailing address

18 TURKEY HILL RD
NEWTOWN CT
06470-2314
US

V. Phone/Fax

Practice location:
  • Phone: 203-775-6205
  • Fax:
Mailing address:
  • Phone: 203-947-4621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number23.004823
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: