MEDICARE: MR. TODD K. BERGAN PA

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	363A00000X	Physician Assistant	PA9102600	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1245213966
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TODD K. BERGAN PA

Provider Business Mailing Address
First Line	:	1860 RENZULLI ROAD
Second Line	:
City	:	NEW SMYRNA BEACH
State	:	FL
Zip	:	32168-1726
Country	:	US
Telephone Number	:	386-663-3064
Fax Number	:

Provider Business Practice Location Address
First Line	:	1860 RENZULLI ROAD
Second Line	:
City	:	NEW SMYRNA BEACH
State	:	FL
Zip	:	32168-1726
Country	:	US
Telephone Number	:	386-663-3064
Fax Number	:

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

Provider Enumeration Date	:	11/28/2005
Last Update Date	:	02/17/2010

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Directions to “ MR. TODD K. BERGAN PA” Practice Location

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