Provider Demographics
NPI:1386740793
Name:JORGE J. BERGESE, MD INC.
Entity type:Organization
Organization Name:JORGE J. BERGESE, MD INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:J
Authorized Official - Last Name:BERGESE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-756-1125
Mailing Address - Street 1:370 CLINE AVE
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44907-1057
Mailing Address - Country:US
Mailing Address - Phone:419-756-1125
Mailing Address - Fax:419-756-1825
Practice Address - Street 1:370 CLINE AVE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44907-1057
Practice Address - Country:US
Practice Address - Phone:419-756-1125
Practice Address - Fax:419-756-1825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0221307Medicaid
OH0221307Medicaid