Basic Information
| Provider Information | |||||||||
| NPI: | 1255529079 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERGMAN | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | MARGARET | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 MARINER HEALTH WAY STE 213 | ||||||||
| Address2: | |||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320863251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042174259 | ||||||||
| FaxNumber: | 9042174251 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 MARINER HEALTH WAY STE 213 | ||||||||
| Address2: | |||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320863251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042174259 | ||||||||
| FaxNumber: | 9042174251 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2007 | ||||||||
| LastUpdateDate: | 02/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 23557 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PTP-PT-LIC-9465 | MT | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT36674 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 23557 | 05 | FL | MEDICAID |