Healthcare Provider Details

I. General information

NPI: 1932172277
Provider Name (Legal Business Name): HEATHER LINEE BERGESON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HEATHER LINEE JOHNSON MD

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 03/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 NORTHLAND DRIVE
BLOOMINGTON MN
55431
US

IV. Provider business mailing address

8170 33RD AVE S PO BOX 1309 MAIL STOP 21110Q
MINNEAPOLIS MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 952-831-8742
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number44300
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: