Provider Demographics
NPI:1427081280
Name:BERGIN, ANN MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:ANN
Middle Name:MARIE
Last Name:BERGIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 LONGWOOD AVE
Mailing Address - Street 2:FEGAN 11
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5724
Mailing Address - Country:US
Mailing Address - Phone:617-355-6815
Mailing Address - Fax:617-730-0463
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:FEGAN 11
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:617-355-6815
Practice Address - Fax:617-730-0463
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA207935208000000X, 2084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0117285Medicaid
MA0117285Medicaid
G48858Medicare UPIN