MEDICARE: DR. DEREK SCOTT BERGESON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	12767278-1205	UT

General Provider Information

NPI Number	:	1164641387
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DEREK SCOTT BERGESON MD

Provider Business Mailing Address
First Line	:	1055 N 500 W
Second Line	:	ATTN CREDENTIALING
City	:	PROVO
State	:	UT
Zip	:	84604
Country	:	US
Telephone Number	:	801-354-8225
Fax Number	:	801-418-0941

Provider Business Practice Location Address
First Line	:	1055 N 500 W
Second Line	:	ATTN CREDENTIALING
City	:	PROVO
State	:	UT
Zip	:	84604-8460
Country	:	US
Telephone Number	:	801-354-8225
Fax Number	:	801-418-0941

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/25/2007
Last Update Date	:	03/04/2025

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