Healthcare Provider Details

I. General information

NPI: 1669400024
Provider Name (Legal Business Name): RUSSELL ALAN BERGUM D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 08/16/2023
Certification Date: 08/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2560 2ND ST SW STE 120
ROCHESTER MN
55902-4363
US

IV. Provider business mailing address

2560 2ND ST SW STE 120
ROCHESTER MN
55902-4363
US

V. Phone/Fax

Practice location:
  • Phone: 507-361-0400
  • Fax: 866-371-6710
Mailing address:
  • Phone: 507-361-0400
  • Fax: 866-371-6710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number42602
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: