Provider Demographics
NPI:1063551299
Name:BERGAN, ROBERT WILLIAM (DC)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:WILLIAM
Last Name:BERGAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 HENNEPIN AVE SOUTH
Mailing Address - Street 2:SUITE #210
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55405
Mailing Address - Country:US
Mailing Address - Phone:612-871-0700
Mailing Address - Fax:612-874-9827
Practice Address - Street 1:2101 HENNEPIN AVE SOUTH
Practice Address - Street 2:SUITE #210
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55405
Practice Address - Country:US
Practice Address - Phone:612-871-0700
Practice Address - Fax:612-874-9827
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1232111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN01250BEOtherBLUE CROSS BLUE SHIELD
MN01250BEOtherBLUE CROSS BLUE SHIELD