Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | 3888-012 | WI |
NPI | 1477630564 |
---|---|
Provider Name | Jerod Joseph Bergman |
First Address | Rhinelander, WI 54501-3314 |
Second Address | Rhinelander, WI 54501-3314 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/11/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
38942100 | (05) | WI |
U93605 | (02) | WI |