Provider Demographics
NPI:1306965371
Name:BERGMAN, ROGER BURT (PA)
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:BURT
Last Name:BERGMAN
Suffix:
Gender:M
Credentials:PA
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Other - Credentials:
Mailing Address - Street 1:1000 QUAYSIDE TER
Mailing Address - Street 2:APT 1904
Mailing Address - City:MIAMI SHORES
Mailing Address - State:FL
Mailing Address - Zip Code:33138-2243
Mailing Address - Country:US
Mailing Address - Phone:305-895-6659
Mailing Address - Fax:
Practice Address - Street 1:7000 SW 62ND AVE
Practice Address - Street 2:SUITE 545
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-4716
Practice Address - Country:US
Practice Address - Phone:305-669-6166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9100770363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant