MEDICARE: DR. DONNA C 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	2084N0400X	Neurology Physician	036045728	IL
2	2084N0600X	Clinical Neurophysiology Physician	036045728	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	336012506	OTHER	IL	CONTROLLED
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548256357
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DONNA C BERGEN MD

Provider Business Mailing Address
First Line	:	1725 W HARRISON ST
Second Line	:	1106
City	:	CHICAGO
State	:	IL
Zip	:	60612-3841
Country	:	US
Telephone Number	:	312-942-4500
Fax Number	:	312-942-2380

Provider Business Practice Location Address
First Line	:	1725 W HARRISON ST
Second Line	:	1106
City	:	CHICAGO
State	:	IL
Zip	:	60612-3841
Country	:	US
Telephone Number	:	312-942-5936
Fax Number	:

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

Provider Enumeration Date	:	09/27/2005
Last Update Date	:	03/07/2023

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