Provider Demographics
NPI:1053392282
Name:BERMINGHAM, ROGER P (M D)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:P
Last Name:BERMINGHAM
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 PENNOCK PL
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-3257
Mailing Address - Country:US
Mailing Address - Phone:970-495-8800
Mailing Address - Fax:970-495-8820
Practice Address - Street 1:1025 PENNOCK PL
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-3257
Practice Address - Country:US
Practice Address - Phone:970-495-8800
Practice Address - Fax:970-495-8820
Is Sole Proprietor?:No
Enumeration Date:2005-11-05
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO22982207QG0300X
CODR.0022982207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
COP01135769OtherRAILROAD MEDICARE
CO01229822Medicaid
CO01229822Medicaid
COD24187Medicare UPIN
COR0645298OtherBCBS GROUP
CO01229822Medicaid
COD24187Medicare UPIN
COC9351Medicare ID - Type Unspecified