Basic Information
| Provider Information | |||||||||
| NPI: | 1851346654 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERGMARK | ||||||||
| FirstName: | KIRK | ||||||||
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| Credential: | A.P.R.N.,C.N.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12251 S 80TH AVE STE 202 | ||||||||
| Address2: | |||||||||
| City: | PALOS HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604631290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7089237878 | ||||||||
| FaxNumber: | 7089237888 | ||||||||
| Practice Location | |||||||||
| Address1: | 15300 WEST AVE | ||||||||
| Address2: | SUITE 313 | ||||||||
| City: | ORLAND PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604624600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7089237878 | ||||||||
| FaxNumber: | 7089237888 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 01/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 277.000284 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 364SP0808X | 277000284 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health | 364SP0809X | 277000284 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Adult |
No ID Information.