Provider Demographics
NPI:1215941117
Name:WATERTOWN ANESTHESIA PC
Entity type:Organization
Organization Name:WATERTOWN ANESTHESIA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:O
Authorized Official - Last Name:BERGSBAKEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:605-335-1952
Mailing Address - Street 1:PO BOX 3353
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-0353
Mailing Address - Country:US
Mailing Address - Phone:605-335-1952
Mailing Address - Fax:605-373-9971
Practice Address - Street 1:401 9TH AVE NW
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-1548
Practice Address - Country:US
Practice Address - Phone:605-882-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CH3925OtherRAILROAD MEDICARE
MN574572100Medicaid
MN31K20WAOtherBCBS - GROUP
CH3925OtherRAILROAD MEDICARE
SDS7247Medicare PIN