Provider Demographics
NPI:1053428573
Name:BERGERON, KURT
Entity type:Individual
Prefix:
First Name:KURT
Middle Name:
Last Name:BERGERON
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 1:73 NEWTON RD
Mailing Address - Street 2:STE 101
Mailing Address - City:PLAISTOW
Mailing Address - State:NH
Mailing Address - Zip Code:03865-2424
Mailing Address - Country:US
Mailing Address - Phone:978-388-7272
Mailing Address - Fax:978-388-7373
Practice Address - Street 1:282 STATE ROUTE 101
Practice Address - Street 2:UNIT 11
Practice Address - City:AMHERST
Practice Address - State:NH
Practice Address - Zip Code:03031-1706
Practice Address - Country:US
Practice Address - Phone:603-372-5125
Practice Address - Fax:603-372-5126
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH2757225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH000184301OtherMEDICARE PTAN
NH000184301OtherMEDICARE PTAN