Provider Demographics
NPI:1962455220
Name:BERGIN, JOHN R (PA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:BERGIN
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:315 S MANNING BLVD
Mailing Address - Street 2:ST PETER'S HOSPITAL
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-1707
Mailing Address - Country:US
Mailing Address - Phone:518-525-1550
Mailing Address - Fax:
Practice Address - Street 1:315 S MANNING BLVD
Practice Address - Street 2:ST PETER'S HOSPITAL
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-1707
Practice Address - Country:US
Practice Address - Phone:518-525-1550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2010-02-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY000476363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY384107OtherMVP
NY050316000062OtherFIDELIS
NY000496464003OtherBLUE SHIELD
NY000496464003OtherBLUE SHIELD
NYR53830Medicare UPIN