Basic Information
| Provider Information | |||||||||
| NPI: | 1164464913 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERGSMAN | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 321061 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482321061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485438070 | ||||||||
| FaxNumber: | 2485439005 | ||||||||
| Practice Location | |||||||||
| Address1: | 27207 LAHSER RD | ||||||||
| Address2: | SUITE 200 B | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480342168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483584892 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 08/18/2010 | ||||||||
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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 | 207R00000X | 4301028293 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0003X | 4301028293 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 4482104 | 05 | MI | MEDICAID |