Healthcare Provider Details

I. General information

NPI: 1487256038
Provider Name (Legal Business Name): JOSEPH PAUL BERGUM OTR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2020
Last Update Date: 11/09/2020
Certification Date: 11/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26900 FRANKLIN RD
SOUTHFIELD MI
48033-5312
US

IV. Provider business mailing address

26900 FRANKLIN RD
SOUTHFIELD MI
48033-5312
US

V. Phone/Fax

Practice location:
  • Phone: 248-350-8070
  • Fax: 248-350-8078
Mailing address:
  • Phone: 248-350-8070
  • Fax: 248-350-8078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201003453
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: