MEDICARE: SANDRA MELODY BERGLUND D.O.

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	207Q00000X	Family Medicine Physician	34.005605	OH

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

General Provider Information

NPI Number	:	1306952320
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA MELODY BERGLUND D.O.

Provider Business Mailing Address
First Line	:	18660 BAGLEY RD
Second Line	:	BUILDING 1, SUITE 201
City	:	CLEVELAND
State	:	OH
Zip	:	44130-3483
Country	:	US
Telephone Number	:	440-239-9077
Fax Number	:	440-239-9080

Provider Business Practice Location Address
First Line	:	18660 BAGLEY RD
Second Line	:	BUILDING 1, SUITE 201
City	:	CLEVELAND
State	:	OH
Zip	:	44130-3483
Country	:	US
Telephone Number	:	440-239-9077
Fax Number	:	440-239-9080

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

Provider Enumeration Date	:	08/22/2006
Last Update Date	:	07/08/2007

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