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General NPI Number Information
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NPI Number | 1447281662
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Entity Type | Individual
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Provider Name | CORWYN B BERGSMA D.P.M.
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Gender | Male
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Dates
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Enumeration Date | 07/05/2006
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Last Update Date | 12/27/2021
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Provider Practice Location Address
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Address Line | 1195 WILSON AVE NW SUITE 200
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City | GRAND RAPIDS
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State | MI
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Zip | 49534-6405
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Country | US
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Telephone | 616-453-8277
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Fax | 616-453-2002
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Provider Business Mailing Address
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Address Line | 4540 KALAMAZOO AVE SE
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City | KENTWOOD
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State | MI
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Zip | 49508-4625
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Country | US
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Telephone | 616-281-0666
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Fax | 616-281-0752
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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 | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | 5901002157
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License Number State | MI
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