Healthcare Provider Details

I. General information

NPI: 1346602893
Provider Name (Legal Business Name): SEAN BERGSTEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2016
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 MEMORIAL DR
POCATELLO ID
83201-4008
US

IV. Provider business mailing address

500 S 11TH AVE STE 400
POCATELLO ID
83201-4880
US

V. Phone/Fax

Practice location:
  • Phone: 208-234-4700
  • Fax:
Mailing address:
  • Phone: 208-232-7862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberO-1393
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: