=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386952844
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SKILLED MEDICAL PROVIDER GROUP PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2010
-----------------------------------------------------
Last Update Date | 09/18/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13 SURREY LN
-----------------------------------------------------
City | DURHAM
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03824-4413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-459-4522
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13 SURREY LN
-----------------------------------------------------
City | DURHAM
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03824-4413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-459-4522
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DR. PAUL P BERGERON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 603-459-4522
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------