Basic Information
| Provider Information | |||||||||
| NPI: | 1871577304 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERGMAN | ||||||||
| FirstName: | SIMON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 344 | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271020344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162255 | ||||||||
| FaxNumber: | 3367167595 | ||||||||
| Practice Location | |||||||||
| Address1: | MEDICAL CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271570001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162255 | ||||||||
| FaxNumber: | 3367167595 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2005 | ||||||||
| LastUpdateDate: | 08/19/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0101X | 99-00765 | NC | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology | 207ZC0500X | 99-00765 | NC | N | Allopathic & Osteopathic Physicians | Pathology | Cytopathology |
ID Information
| ID | Type | State | Issuer | Description | 88713 | 01 | MEDCOST | OTHER | 7222325 | 01 | AETNA | OTHER | 891211X | 05 | NC | MEDICAID | 32153 | 01 | PARTNERS | OTHER | 1211X | 01 | BCBS | OTHER | 9801025000 | 05 | WV | MEDICAID | Q00765 | 05 | SC | MEDICAID | 6605176 | 05 | VA | MEDICAID |