Healthcare Provider Details

I. General information

NPI: 1912902784
Provider Name (Legal Business Name): GREGORY ALAN BERGMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 02/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4463 STATE ROUTE 66N
MINSTER OH
45865-8727
US

IV. Provider business mailing address

1002 S KNOXVILLE AVE GRAND LAKE PHYSICIAN PRACTICES
SAINT MARYS OH
45885-2607
US

V. Phone/Fax

Practice location:
  • Phone: 419-394-3387
  • Fax: 419-628-9501
Mailing address:
  • Phone: 419-394-3387
  • Fax: 419-628-9501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number047703
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: