Healthcare Provider Details

I. General information

NPI: 1093719866
Provider Name (Legal Business Name): THOMAS M BERGAMINI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 02/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4003 KRESGE WAY STE 300
LOUISVILLE KY
40207-4652
US

IV. Provider business mailing address

4003 KRESGE WAY STE 300
LOUISVILLE KY
40207-4652
US

V. Phone/Fax

Practice location:
  • Phone: 502-897-5139
  • Fax: 502-896-6218
Mailing address:
  • Phone: 502-897-5139
  • Fax: 502-896-6218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number23369
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: