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General NPI Number Information
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NPI Number | 1386841914
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Entity Type | Individual
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Provider Name | JILL C BERGSON MD
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Gender | Female
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Dates
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Enumeration Date | 06/28/2007
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Last Update Date | 01/02/2020
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Provider Practice Location Address
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Address Line | 1300 ROANOKE AVE
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City | RIVERHEAD
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State | NY
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Zip | 11901-2031
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Country | US
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Telephone | 631-548-6172
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Fax |
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Provider Business Mailing Address
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Address Line | 27005 76TH AVE
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City | NEW HYDE PARK
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State | NY
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Zip | 11040-1402
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Country | US
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Telephone | 516-562-4810
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 287348-1
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License Number State | NY
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