Basic Information
| Provider Information | |||||||||
| NPI: | 1336331065 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERGTHOLD | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | MSN-ACNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1500 | ||||||||
| Address2: | |||||||||
| City: | OSAGE BEACH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 650651500 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 54 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | OSAGE BEACH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 650653050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733022287 | ||||||||
| FaxNumber: | 5733022241 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2007 | ||||||||
| LastUpdateDate: | 12/07/2012 | ||||||||
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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 | 363LA2100X | 139652 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 1336331065 | 05 | MO | MEDICAID | 135570015 | 01 | MO | MEDICARE PTAN | OTHER | P00750268 | 01 | MO | RAIL ROAD MEDICARE | OTHER |