Healthcare Provider Details

I. General information

NPI: 1609021104
Provider Name (Legal Business Name): STEPHEN RUSSELL BERGMAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2008
Last Update Date: 03/20/2023
Certification Date: 03/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6965 CUMBERLAND GAP PKWY
HARROGATE TN
37752-8245
US

IV. Provider business mailing address

146 BRITTAIN DR
HARROGATE TN
37752-7018
US

V. Phone/Fax

Practice location:
  • Phone: 423-869-6249
  • Fax:
Mailing address:
  • Phone: 720-838-6700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number2007018743
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberE-12201
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number2007018743
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberE-12201
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: