Provider Demographics
NPI:1104901420
Name:BERGAM, MIRO (MD)
Entity type:Individual
Prefix:
First Name:MIRO
Middle Name:
Last Name:BERGAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25B VREELAND RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:FLORHAM PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07932-1900
Mailing Address - Country:US
Mailing Address - Phone:973-660-9334
Mailing Address - Fax:973-660-9779
Practice Address - Street 1:94 OLD SHORT HILLS RD
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-5672
Practice Address - Country:US
Practice Address - Phone:973-322-5512
Practice Address - Fax:973-322-8165
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06868600207L00000X, 207LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7919409Medicaid
NJ7919409Medicaid
NJ033094CNKMedicare PIN