Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0120X | Pediatric Surgery | 25MA05619600 | NJ |
NPI | 1346211174 |
---|---|
Provider Name | Kerry Bergman |
First Address | Newark, NJ 07189-0001 |
Second Address | Summit, NJ 07901-3533 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/01/2006 |
Last Update Date | 17/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
E84407 | (02) | NJ |