Basic Information
| Provider Information | |||||||||
| NPI: | 1942299730 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERGERSEN | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD MPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9135 | ||||||||
| Address2: | ATT:SHARON SILVA | ||||||||
| City: | BROOKLINE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024469135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6038904404 | ||||||||
| FaxNumber: | 6038938886 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 LONGWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021155724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6173357893 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2005 | ||||||||
| LastUpdateDate: | 11/21/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | 160372 | MA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 208000000X | 160372 | MA | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0202X | 160372 | MA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 2039290 | 05 | MA | MEDICAID | 28244 | 01 | MA | BMC HEALTHNET | OTHER | J27337 | 01 | MA | HMO BLUE | OTHER | J27337 | 01 | MA | BCBS MA | OTHER | 468809 | 01 | MA | TUFTS HEALTH PLAN | OTHER | 96969201 | 01 | MA | NETWORK HEALTH | OTHER | 2501928 | 01 | MA | UNITED HEALTHCARE MA | OTHER | J27337 | 01 | MA | BLUE CARE ELECT | OTHER | LB54040 | 05 | RI | MEDICAID |