Basic Information
| Provider Information | |||||||||
| NPI: | 1578854840 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERGESON | ||||||||
| FirstName: | KERI | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 ORONDO AVE STE 1 | ||||||||
| Address2: | |||||||||
| City: | WENATCHEE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988012800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096626000 | ||||||||
| FaxNumber: | 5096644590 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 S APPLE BLOSSOM DR | ||||||||
| Address2: | |||||||||
| City: | CHELAN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096826000 | ||||||||
| FaxNumber: | 5096826192 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2011 | ||||||||
| LastUpdateDate: | 08/28/2018 | ||||||||
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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 | 207Q00000X | BC60504507 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2039181 | 05 | WA | MEDICAID |