Provider Demographics
NPI:1063625150
Name:MARY F. BERGUM, MD, PLLC
Entity type:Organization
Organization Name:MARY F. BERGUM, MD, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:F
Authorized Official - Last Name:BERGUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-448-4870
Mailing Address - Street 1:3154 E 29TH AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99223-4852
Mailing Address - Country:US
Mailing Address - Phone:509-448-4870
Mailing Address - Fax:800-976-4305
Practice Address - Street 1:3154 E 29TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99223-4852
Practice Address - Country:US
Practice Address - Phone:509-448-4870
Practice Address - Fax:800-976-4305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00042807207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty