Basic Information
| Provider Information | |||||||||
| NPI: | 1346478658 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERGIN | ||||||||
| FirstName: | SUZANNE | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WHEELER | ||||||||
| OtherFirstName: | SUZANNE | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9 CAREY RD | ||||||||
| Address2: | |||||||||
| City: | QUEENSBURY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128047880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187610300 | ||||||||
| FaxNumber: | 5188242388 | ||||||||
| Practice Location | |||||||||
| Address1: | 3767 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WARRENSBURG | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128851890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5186232844 | ||||||||
| FaxNumber: | 5186233416 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2009 | ||||||||
| LastUpdateDate: | 04/04/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 266542 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 03525440 | 05 | NY | MEDICAID |