=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518960715
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RACHEL BERGESON MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 STADIUM RD
-----------------------------------------------------
City | STONYBROOK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11794-3191
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-632-6740
-----------------------------------------------------
Fax | 631-632-6936
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3 SCHOONER CV
-----------------------------------------------------
City | SETAUKET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11733-3951
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-689-9346
-----------------------------------------------------
Fax | 631-632-6936
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080A0000X
-----------------------------------------------------
Taxonomy Name | Pediatric Adolescent Medicine Physician
-----------------------------------------------------
License Number | 146309
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------