MEDICARE: MR. FRED J BERGANINI BC-HIS

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	174400000X	Specialist	4186	AL

General Provider Information

NPI Number	:	1649631888
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. FRED J BERGANINI BC-HIS

Provider Business Mailing Address
First Line	:	6125 UNIVERSITY DR NW
Second Line	:	SUITE A14
City	:	HUNTSVILLE
State	:	AL
Zip	:	35806-1757
Country	:	US
Telephone Number	:	256-922-0004
Fax Number	:

Provider Business Practice Location Address
First Line	:	6125 UNIVERSITY DR NW
Second Line	:	SUITE A14
City	:	HUNTSVILLE
State	:	AL
Zip	:	35806-1757
Country	:	US
Telephone Number	:	256-922-0004
Fax Number	:

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

Provider Enumeration Date	:	03/16/2016
Last Update Date	:	03/16/2016

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