Healthcare Provider Details

I. General information

NPI: 1013966563
Provider Name (Legal Business Name): MICHAEL A. BERGEVIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 CHILDRENS LN
NORFOLK VA
23507-1910
US

IV. Provider business mailing address

PO BOX 79137
BALTIMORE MD
21279-0137
US

V. Phone/Fax

Practice location:
  • Phone: 757-668-7007
  • Fax: 757-668-8658
Mailing address:
  • Phone: 757-668-7200
  • Fax: 757-668-9691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0213X
TaxonomyPediatric Pathology Physician
License Number0101044312
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number0101044312
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: