Provider Demographics
NPI:1912902784
Name:BERGMAN, GREGORY ALAN (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:ALAN
Last Name:BERGMAN
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 1:1002 S KNOXVILLE AVE
Mailing Address - Street 2:GRAND LAKE PHYSICIAN PRACTICES
Mailing Address - City:SAINT MARYS
Mailing Address - State:OH
Mailing Address - Zip Code:45885-2607
Mailing Address - Country:US
Mailing Address - Phone:419-394-3387
Mailing Address - Fax:419-628-9501
Practice Address - Street 1:4463 STATE ROUTE 66N
Practice Address - Street 2:
Practice Address - City:MINSTER
Practice Address - State:OH
Practice Address - Zip Code:45865-8727
Practice Address - Country:US
Practice Address - Phone:419-394-3387
Practice Address - Fax:419-628-9501
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH047703207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0537502Medicaid
OH1104024546OtherORGANIZATIONAL NPI
OH2268237OtherMEDICAID LEGACY
OH9934723OtherMEDICARE PTAN
OHBE0553544Medicare PIN