Provider Demographics
NPI:1861176513
Name:BERGMAN, BRANDON SCOTT
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:SCOTT
Last Name:BERGMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 PROVIDENCE PL APT 346
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-7011
Mailing Address - Country:US
Mailing Address - Phone:857-204-3200
Mailing Address - Fax:
Practice Address - Street 1:903 PROVIDENCE PL APT 346
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-7011
Practice Address - Country:US
Practice Address - Phone:857-204-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-13
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker