MEDICARE: DR. JEFFREY KEITH BERGIN DC, DABCI

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	111NI0900X	Internist Chiropractor	038-004780	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	743871001	OTHER	IL	MEDICARE PTAN

General Provider Information

NPI Number	:	1265495675
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY KEITH BERGIN DC, DABCI

Provider Business Mailing Address
First Line	:	2629 SHERIDAN RD
Second Line	:	SUITE 1A
City	:	ZION
State	:	IL
Zip	:	60099-2629
Country	:	US
Telephone Number	:	847-872-8230
Fax Number	:	847-872-8208

Provider Business Practice Location Address
First Line	:	2629 SHERIDAN RD
Second Line	:	SUITE 1A
City	:	ZION
State	:	IL
Zip	:	60099-2629
Country	:	US
Telephone Number	:	847-872-8230
Fax Number	:	847-872-8208

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

Provider Enumeration Date	:	04/07/2006
Last Update Date	:	12/20/2008

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