Basic Information
| Provider Information | |||||||||
| NPI: | 1689629503 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BERGMAN COSMETIC SURGERY, PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DR. RONALD S BERGMAN DO PC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 71602 | ||||||||
| Address2: | |||||||||
| City: | CLIVE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503250602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152432057 | ||||||||
| FaxNumber: | 5152445570 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503124920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152221111 | ||||||||
| FaxNumber: | 5152449914 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 10/15/2020 | ||||||||
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| AuthorizedOfficialLastName: | BERGMAN | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT CEO | ||||||||
| AuthorizedOfficialTelephone: | 5152221111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | 10/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | IA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 208200000X | IA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0422980 | 05 | IA | MEDICAID |