=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639710569
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AUDREY BERGESON MD PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2019
-----------------------------------------------------
Last Update Date | 10/02/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 N HOSPITAL DR
-----------------------------------------------------
City | PRICE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84501-4218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-903-3294
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2102 E DIMPLE DELL RD
-----------------------------------------------------
City | SANDY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84092-4827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-903-3294
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. AUDREY BERGESON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 330-903-3294
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------