Provider Demographics
NPI:1144638412
Name:ANDROSCOGGIN OSTEOPATHIC, LLC,
Entity type:Organization
Organization Name:ANDROSCOGGIN OSTEOPATHIC, LLC,
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:BERGMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:207-241-0945
Mailing Address - Street 1:95 PARK ST
Mailing Address - Street 2:SUITE 519
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-7282
Mailing Address - Country:US
Mailing Address - Phone:207-241-0945
Mailing Address - Fax:207-241-0955
Practice Address - Street 1:95 PARK ST
Practice Address - Street 2:SUITE 519
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7282
Practice Address - Country:US
Practice Address - Phone:207-241-0945
Practice Address - Fax:207-241-0955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-30
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDO2336204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Single Specialty