Basic Information
| Provider Information | |||||||||
| NPI: | 1588626386 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERGSTROM | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | PATRICK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6401 UNIVERSITY AVE NE | ||||||||
| Address2: | |||||||||
| City: | FRIDLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554324341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635725710 | ||||||||
| FaxNumber: | 7635713008 | ||||||||
| Practice Location | |||||||||
| Address1: | 4000 CENTRAL AVE NE | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA HEIGHTS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554212968 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635725710 | ||||||||
| FaxNumber: | 7637828100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2006 | ||||||||
| LastUpdateDate: | 04/06/2012 | ||||||||
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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 | 207R00000X | 44913 | MN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 44913 | MN | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 142969 | 01 | MN | UCARE MN | OTHER | 1032065 | 01 | MN | PREFERRED ONE | OTHER | 1685593 | 01 | MN | AMERICA'S PPO | OTHER | 076642900 | 05 | MN | MEDICAID | HP36617 | 01 | MN | HEALTHPARTNERS | OTHER | 6605839 | 01 | MN | MEDICA UC | OTHER | 0404787 | 01 | MN | MEDICA | OTHER | 65G80BE | 01 | MN | BCBS OF MN | OTHER |