Provider Demographics
NPI:1538165592
Name:BERGEN, BARRY J (MD)
Entity type:Individual
Prefix:DR
First Name:BARRY
Middle Name:J
Last Name:BERGEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 LEWISTON ST
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:ID
Mailing Address - Zip Code:83522-9750
Mailing Address - Country:US
Mailing Address - Phone:208-962-3267
Mailing Address - Fax:208-962-2313
Practice Address - Street 1:701 LEWISTON ST
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:ID
Practice Address - Zip Code:83522-9750
Practice Address - Country:US
Practice Address - Phone:208-962-3267
Practice Address - Fax:208-962-2313
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM48832084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDA07093Medicare UPIN
ID119295Medicare ID - Type UnspecifiedIDA MEDICARE PROV #