Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207X00000X | Orthopaedic Surgeon | 2003-0222 | NM |
N | 207XS0117X | Orthopaedic Spine Surgeon | 41610 | KY |
Y | 207XS0117X | Orthopaedic Spine Surgeon | N2403 | TX |
NPI | 1154460152 |
---|---|
Provider Name | Ryan Bergeson |
First Address | Georgetown, TX 78628-8829 |
Second Address | Georgetown, TX 78628-8842 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/02/2007 |
Last Update Date | 23/06/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000577128 | ANTHEM (SPINE INSTITUTE) (01) | KY |
000000586305 | ANTHEM (UNIV ORTHO ASSOC) (01) | KY |
219591906 | (05) | TX |