Basic Information
| Provider Information | |||||||||
| NPI: | 1982021895 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERGMAN | ||||||||
| FirstName: | CARL | ||||||||
| MiddleName: | JOHAN CHRISTIAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BERGMAN | ||||||||
| OtherFirstName: | CHRISTIAN | ||||||||
| OtherMiddleName: | CARL | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 91734 | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232911734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8043586100 | ||||||||
| FaxNumber: | 8043427619 | ||||||||
| Practice Location | |||||||||
| Address1: | 2116 W LABURNUM AVE | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042543500 | ||||||||
| FaxNumber: | 8042541616 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2014 | ||||||||
| LastUpdateDate: | 08/29/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | 0101260033 | VA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207R00000X | 0101260033 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.