NPIMap

Individual provider Active NPI

Jack William Bergman, PA-C

  • Physician Assistant
  • St Louis Park, MN
National Provider Identifier
1043790553
Registry record updated Jan 17, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
13280 Issued in MN
Practice address
3931 Louisiana Ave S
St Louis Park, MN 55426-5000
Phone
(952) 993-3230
Fax
(952) 993-1748
NPI assigned
Aug 15, 2018
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jan 17, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X 13280 MN Primary

Addresses

Primary practice location

3931 Louisiana Ave S
St Louis Park, MN 55426-5000

Mailing address

3931 Louisiana Ave S
St Louis Park, MN 55426-5000
Phone (952) 993-3230

Other practice location 1

5838 Six Forks Rd Ste 100
Raleigh, NC 27609-3893
Phone (919) 785-3400

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20200129001261 MN Practitioner - Physician Assistant 5698029080 Reassigns benefits to 4 organizations

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2018
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Fairview Express CareGroup PAC ID 3375645179, 1,946 clinicians
Fairview Specialty ServicesGroup PAC ID 3072083286, 303 clinicians
Park Nicollet ClinicGroup PAC ID 7911819438, 1,778 clinicians
Group Health IncGroup PAC ID 1759293954, 1,627 clinicians

Practice addresses (Care Compare)

14101 Fairview Dr
Suite 140
Burnsville, MN 55337-2515
Phone (612) 365-5000

1747 Beam Ave
Suite 100
Maplewood, MN 55109-1128
Phone (651) 232-7800

201 E Nicollet Blvd
Burnsville, MN 55337-5714
Phone (952) 892-2000

3931 Louisiana Ave S
St Louis Park, MN 55426-5000
Phone (952) 993-3123

45 10TH St W
Saint Paul, MN 55102-1062

5320 Hyland Greens Dr
Bloomington, MN 55437-3934
Phone (952) 993-2400

640 Jackson St
Saint Paul, MN 55101-2502
Phone (651) 221-3456

6401 France Ave S
Edina, MN 55435-2104
Phone (952) 924-5000

6500 Excelsior Blvd
St Louis Park, MN 55426-4702
Phone (952) 993-3123

6545 France Ave S
Suite 450
Edina, MN 55435-2122
Phone (952) 848-5600

717 Delaware St SE
Suite 340
Minneapolis, MN 55414-2959
Phone (612) 672-7422

8600 Nicollet Ave
Bloomington, MN 55420-2824
Phone (952) 884-1148

Hospital & facility affiliations

  • Park Nicollet Methodist Hospital Hospital, Saint Louis Park, MN, CCN 240053
  • M Health Fairview Southdale Hospital Hospital, Edina, MN, CCN 240078
  • M Health Fairview Ridges Hospital Hospital, Burnsville, MN, CCN 240207
  • Fairview Lakes Health Services Hospital, Wyoming, MN, CCN 240050
  • M Health Fairview Woodwinds Hospital Hospital, Woodbury, MN, CCN 240213

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
13280MNMDPsychiatric/Mental Health Nurse Practitioner

Practice roles

OrganizationSpecialtyStatusNew patients
Park Nicollet Clinic CurrentSince Jan 27, 2020 Accepting new patients
Healtheast Medical Research Institute Current Accepting new patients
Fairview Express Care CurrentSince Dec 1, 2025 Accepting new patients
Fairview Express Care CurrentSince Dec 1, 2025 Accepting new patients
Healtheast Medical Research Institute CurrentSince Dec 1, 2025 Accepting new patients
Group Health, Inc. CurrentSince May 12, 2023 Accepting new patients
Group Health Plan, Inc. CurrentSince May 12, 2023 Accepting new patients
Healtheast Medical Research Insititue CurrentSince Dec 1, 2025 Accepting new patients
Fairview Express Care Current Accepting new patients

Locations

8600 Nicollet Ave S
Minneapolis, MN 55420
Phone (952) 887-6600

717 Delaware St SE
Ste 340
Minneapolis, MN 55414
Phone (612) 625-3617

5320 Hyland Greens Dr
Minneapolis, MN 55437
Phone (952) 993-2400

1700 University Ave W
Fl 6
Saint Paul, MN 55104
Phone (651) 232-2273

15290 Pennock Ln
Saint Paul, MN 55124
Phone (952) 431-8500

3931 Louisiana Ave S
St Louis Park, MN 55426
Phone (952) 993-3230

Organizations & group practices 12

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 12

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1534291200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1579219200000",
    "number": "1043790553",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3931 LOUISIANA AVE S",
            "city": "ST LOUIS PARK",
            "state": "MN",
            "postal_code": "554265000",
            "telephone_number": "952-993-3230",
            "fax_number": "952-993-1748"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3931 LOUISIANA AVE S",
            "city": "ST LOUIS PARK",
            "state": "MN",
            "postal_code": "554265000",
            "telephone_number": "952-993-3230",
            "fax_number": "952-993-1748"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "5838 Six Forks Rd Ste 100",
            "address_purpose": "LOCATION",
            "city": "Raleigh",
            "state": "NC",
            "postal_code": "276093893",
            "country_code": "US",
            "telephone_number": "919-785-3400",
            "fax_number": "919-783-7778",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "BERGMAN",
        "first_name": "JACK",
        "middle_name": "WILLIAM",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2018-08-15",
        "last_updated": "2020-01-17",
        "certification_date": "2020-01-17",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "MN",
            "license": "13280",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in St Louis Park, MN

Sources for this page

Verify at the official NPI Registry.