Healthcare Provider Details

I. General information

NPI: 1982718706
Provider Name (Legal Business Name): LYNN MARIE BERGQUIST M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 VINE STREET DEPT OF VETERANS AFFAIRS MEDICAL CENTER
CINCINNATI OH
45220-2447
US

IV. Provider business mailing address

2980 ERIE AVE
CINCINNATI OH
45208-2447
US

V. Phone/Fax

Practice location:
  • Phone: 513-861-3100
  • Fax: 513-475-6528
Mailing address:
  • Phone: 513-861-3100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35078777
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: