Healthcare Provider Details

I. General information

NPI: 1962791657
Provider Name (Legal Business Name): BETH M MARSHALL-BERGMAN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BETH M MARSHALL

II. Dates (important events)

Enumeration Date: 04/04/2011
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 S WACKER DR STE 300
CHICAGO IL
60606-4421
US

IV. Provider business mailing address

109 STATE ST STE 5
BOSTON MA
02109-2906
US

V. Phone/Fax

Practice location:
  • Phone: 617-505-1520
  • Fax: 617-928-8401
Mailing address:
  • Phone: 617-505-1520
  • Fax: 617-928-8401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4856
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number3894
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC0750
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036.135673
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2877
License Number StateAL
# 6
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberEMC0001956
License Number StateMI
# 7
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number30199
License Number StateMS
# 8
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number91988
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: