Healthcare Provider Details

I. General information

NPI: 1154460152
Provider Name (Legal Business Name): RYAN BERGESON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 06/23/2020
Certification Date: 06/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 LEANDER RD STE 101
GEORGETOWN TX
78628-8842
US

IV. Provider business mailing address

1520 LEANDER RD STE 100
GEORGETOWN TX
78628-8829
US

V. Phone/Fax

Practice location:
  • Phone: 512-942-2499
  • Fax: 512-943-0001
Mailing address:
  • Phone: 512-942-2499
  • Fax: 512-943-0001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number2003-0222
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number41610
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberN2403
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: