Basic Information
| Provider Information | |||||||||
| NPI: | 1063493740 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERGMAN | ||||||||
| FirstName: | A. GABRIELLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8 CADILLAC DRIVE | ||||||||
| Address2: | 200 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153767360 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8 CADILLAC DR | ||||||||
| Address2: | STE 200 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275087 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153767370 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2005 | ||||||||
| LastUpdateDate: | 03/26/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | A45426 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 807558000 | 05 | ID | MEDICAID | 3002596 | 05 | TN | MEDICAID | 000000391170 | 01 | OH | BCBS | OTHER | 23482101 | 05 | AZ | MEDICAID | 00A454260 | 05 | CA | MEDICAID | 00A454260 | 01 | CA | BCBS | OTHER | P00146079 | 01 | RXR MCR | OTHER | 2510143 | 05 | OH | MEDICAID |