Basic Information
| Provider Information | |||||||||
| NPI: | 1639710569 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AUDREY BERGESON MD PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2102 E DIMPLE DELL RD | ||||||||
| Address2: | |||||||||
| City: | SANDY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840924827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3309033294 | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 N HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | PRICE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 845014218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3309033294 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2019 | ||||||||
| LastUpdateDate: | 10/02/2019 | ||||||||
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| AuthorizedOfficialLastName: | BERGESON | ||||||||
| AuthorizedOfficialFirstName: | AUDREY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3309033294 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.