MEDICARE: DR. KENDRA GAIL BERGSTROM M.D.

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	207N00000X	Dermatology Physician	238443	NY
2	207N00000X	Dermatology Physician	MD60117060	WA

General Provider Information

NPI Number	:	1194764837
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENDRA GAIL BERGSTROM M.D.

Provider Business Mailing Address
First Line	:	5546 CANFIELD PL N
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98103-5920
Country	:	US
Telephone Number	:	917-596-5161
Fax Number	:

Provider Business Practice Location Address
First Line	:	4225 ROOSEVELT WAY NE FL 4
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98105-6099
Country	:	US
Telephone Number	:	206-598-4067
Fax Number	:

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

Provider Enumeration Date	:	06/06/2006
Last Update Date	:	03/17/2018

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