Basic Information
| Provider Information | |||||||||
| NPI: | 1053428573 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | BERGERON | ||||||||
| FirstName: | KURT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 73 NEWTON RD | ||||||||
| Address2: | STE 101 | ||||||||
| City: | PLAISTOW | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038652424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9783887272 | ||||||||
| FaxNumber: | 9783887373 | ||||||||
| Practice Location | |||||||||
| Address1: | 282 STATE ROUTE 101 | ||||||||
| Address2: | UNIT 11 | ||||||||
| City: | AMHERST | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030311706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6033725125 | ||||||||
| FaxNumber: | 6033725126 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 06/25/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2757 | NH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 000184301 | 01 | NH | MEDICARE PTAN | OTHER |