Provider Demographics
NPI:1396708566
Name:BERGIN, JAMES TODD (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:TODD
Last Name:BERGIN
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:PO BOX 347
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:KY
Mailing Address - Zip Code:42078-0347
Mailing Address - Country:US
Mailing Address - Phone:270-988-3298
Mailing Address - Fax:270-988-4642
Practice Address - Street 1:141 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:KY
Practice Address - Zip Code:42078-8043
Practice Address - Country:US
Practice Address - Phone:270-988-3298
Practice Address - Fax:270-988-4642
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35724174400000X, 208600000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000797438OtherANTHEM BLUE CROSS & BLUE SHIELD
KY64016157Medicaid
KY000000797438OtherANTHEM BLUE CROSS & BLUE SHIELD
KY00087001Medicare ID - Type Unspecified
KYH17690Medicare UPIN
KYK067290Medicare PIN
KYK067292Medicare PIN
KYK067293Medicare PIN