Healthcare Provider Details
I. General information
NPI: 1609884527
Provider Name (Legal Business Name): DIANE K BERGAU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N
II. Dates (important events)
Enumeration Date: 08/04/2006
Last Update Date: 08/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:
III. Provider practice location address
701 W COCOA BEACH CSWY
COCOA BEACH FL
32931-3585
US
IV. Provider business mailing address
PO BOX 2400
MELBOURNE FL
32902-2400
US
V. Phone/Fax
- Phone: 321-799-7111
- Fax: 770-237-4866
- Phone: 866-744-1461
- Fax: 770-621-3181
VI. Provider taxonomy
Scope of Practice (Provider specialty)
| # 1 | |
| Primary Taxonomy | N |
| Taxonomy Code | 2085B0100X |
| Taxonomy | Body Imaging Physician |
| License Number | ME747701 |
| License Number State | FL |
| # 2 | |
| Primary Taxonomy | N |
| Taxonomy Code | 2085N0904X |
| Taxonomy | Nuclear Radiology Physician |
| License Number | ME747701 |
| License Number State | FL |
| # 3 | |
| Primary Taxonomy | N |
| Taxonomy Code | 2085P0229X |
| Taxonomy | Pediatric Radiology Physician |
| License Number | ME747701 |
| License Number State | FL |
| # 4 | |
| Primary Taxonomy | Y |
| Taxonomy Code | 2085R0202X |
| Taxonomy | Diagnostic Radiology Physician |
| License Number | ME747701 |
| License Number State | FL |
| # 5 | |
| Primary Taxonomy | N |
| Taxonomy Code | 2085R0204X |
| Taxonomy | Vascular & Interventional Radiology Physician |
| License Number | ME747701 |
| License Number State | FL |
| # 6 | |
| Primary Taxonomy | N |
| Taxonomy Code | 2085U0001X |
| Taxonomy | Diagnostic Ultrasound Physician |
| License Number | ME747701 |
| License Number State | FL |
VII. Legacy identifiers
For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:
| # 1 | |
| Identifier | 062324500 |
| Identifier Type | MEDICAID |
| Identifier State | FL |
| Identifier Issuer | |
| # 2 | |
| Identifier | 10851U |
| Identifier Type | OTHER |
| Identifier State | FL |
| Identifier Issuer | MEDICARE PTAN |
| # 3 | |
| Identifier | 10851 |
| Identifier Type | OTHER |
| Identifier State | FL |
| Identifier Issuer | BCBS |
| # 4 | |
| Identifier | 30048846 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | MEDICARE RR |
VIII. Authorized Official
Name:
Title or Position:
Credential:
Phone: