Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207X00000X | Orthopaedic Surgeon | 13619 | NE |
Y | 207X00000X | Orthopaedic Surgeon | 17738 | IA |
N | 207XS0106X | Orthopaedic Hand Surgeon | 13619 | NE |
N | 207XS0106X | Orthopaedic Hand Surgeon | 17738 | IA |
NPI | 1023094679 |
---|---|
Provider Name | Richard F Bergstrom |
First Address | Fort Dodge, IA 50501-5740 |
Second Address | Fort Dodge, IA 50501-5742 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/12/2005 |
Last Update Date | 15/09/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
47081915413 | (05) | NE |
B67832 | (02) |