Basic Information
| Provider Information | |||||||||
| NPI: | 1902892987 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERGMAN | ||||||||
| FirstName: | MELANIE | ||||||||
| MiddleName: | KIM | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SNYDER | ||||||||
| OtherFirstName: | MELANIE | ||||||||
| OtherMiddleName: | KIM | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 421 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990190421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094742200 | ||||||||
| FaxNumber: | 5092277070 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 W 8TH AVE STE 1400 | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992042307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094742200 | ||||||||
| FaxNumber: | 5092277070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2005 | ||||||||
| LastUpdateDate: | 04/16/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0201X | MD00041339 | WA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology |
ID Information
| ID | Type | State | Issuer | Description | 0161207 | 01 | WA | LABOR & INDUSTRIES | OTHER | 7711025 | 01 | AETNA | OTHER | 000010139925 | 01 | BLUE SHIELD OF IDAHO | OTHER | 8095SN | 01 | WA | ASURIS NW HEALTH | OTHER | KS038 | 01 | BLUE CROSS OF IDAHO | OTHER | 8316663 | 05 | WA | MEDICAID | 980000404 | 01 | RAILROAD MEDICARE | OTHER | 806372200 | 05 | ID | MEDICAID |