Healthcare Provider Details

I. General information

NPI: 1689629503
Provider Name (Legal Business Name): BERGMAN COSMETIC SURGERY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 GRAND AVE
DES MOINES IA
50312-4920
US

IV. Provider business mailing address

PO BOX 71602
CLIVE IA
50325-0602
US

V. Phone/Fax

Practice location:
  • Phone: 515-222-1111
  • Fax: 515-244-9914
Mailing address:
  • Phone: 515-243-2057
  • Fax: 515-244-5570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateIA

VIII. Authorized Official

Name: DR. RONALD S BERGMAN
Title or Position: PRESIDENT CEO
Credential: DO
Phone: 515-222-1111