Individual
BRENT D BERGEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
3800 S NATIONAL AVE STE 510, SPRINGFIELD, MO 65807-5284
(417) 875-3160
Mailing address
PO BOX 9007, SPRINGFIELD, MO 65808-9007
(417) 875-3462
Taxonomy
Speciality
Code
Description
License number
State
207RP1001X
Pulmonary Disease Physician
Primary
2007001545
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000048062
ANTHEM BCBS
KY
01
—
1069441
PASSPORT HEALTH
KY
05
—
200096100A
—
IN
05
—
204593909
—
MO
01
—
290009315
RR MEDICARE
—
05
—
64319783
—
KY
Enumeration date
08/10/2005
Last updated
12/27/2018
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