Basic Information
Provider Information | |||||||||
NPI: | 1407111768 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BERGLAND | ||||||||
FirstName: | BERT | ||||||||
MiddleName: | EUGENE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5920 MCINTYRE ST | ||||||||
Address2: |   | ||||||||
City: | GOLDEN | ||||||||
State: | CO | ||||||||
PostalCode: | 804037445 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3039491250 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 6915 TUTT BLVD STE 110B | ||||||||
Address2: |   | ||||||||
City: | COLORADO SPRINGS | ||||||||
State: | CO | ||||||||
PostalCode: | 809233591 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8888526672 | ||||||||
FaxNumber: | 7195916486 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/11/2012 | ||||||||
LastUpdateDate: | 03/10/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/10/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0505X | DOS-1349 | HI | N |   | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine | 207R00000X | 19594 | CO | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207QA0505X | DR.0019594 | CO | Y |   | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine |
No ID Information.