Healthcare Provider Details

I. General information

NPI: 1225059421
Provider Name (Legal Business Name): CHARLES P. BERGSTROM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 01/29/2021
Certification Date: 01/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 W WISCONSIN AVE PEDIATRIC CRITICAL CARE
MILWAUKEE WI
53226-4874
US

IV. Provider business mailing address

9000 W WISCONSIN AVE PEDIATRIC CRITICAL CARE
MILWAUKEE WI
53226-4874
US

V. Phone/Fax

Practice location:
  • Phone: 414-266-3360
  • Fax: 414-266-3563
Mailing address:
  • Phone: 414-266-3360
  • Fax: 414-266-3563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number248026
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number248026
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number65736
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: