MEDICARE: DR. MICHAEL BERGEN 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	0101267361	VA
2	2085R0204X	Vascular & Interventional Radiology Physician	0101267361	VA
3	208D00000X	General Practice Physician	2756654	NY
4	390200000X	Student in an Organized Health Care Education/Training Program		NY
5	2085R0204X	Vascular & Interventional Radiology Physician	35.146771	OH

General Provider Information

NPI Number	:	1407116718
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL BERGEN MD

Provider Business Mailing Address
First Line	:	9500 EUCLID AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44195-0001
Country	:	US
Telephone Number	:	216-444-6640
Fax Number	:	216-445-1492

Provider Business Practice Location Address
First Line	:	9500 EUCLID AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44195-1838
Country	:	US
Telephone Number	:	216-444-0617
Fax Number	:	216-445-1492

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

Provider Enumeration Date	:	05/21/2012
Last Update Date	:	01/17/2023

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