MEDICARE: KENNETH S BERGMAN 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	2085R0001X	Radiation Oncology Physician	MD00030100	WA

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	:	1669443032
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH S BERGMAN MD

Provider Business Mailing Address
First Line	:	314 MLK JR WAY
Second Line	:	STE 11
City	:	TACOMA
State	:	WA
Zip	:	98405
Country	:	US
Telephone Number	:	253-627-6172
Fax Number	:	253-627-8792

Provider Business Practice Location Address
First Line	:	11511 CANTERWOOD BLVD NW
Second Line	:	SUITE 50
City	:	GIG HARBOR
State	:	WA
Zip	:	98332-5813
Country	:	US
Telephone Number	:	253-851-5155
Fax Number	:	253-851-5367

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

Provider Enumeration Date	:	02/01/2006
Last Update Date	:	08/28/2012

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