Active NPI
Michele Shoshana Bergen, D.M.D., M.D.
- Oral and Maxillofacial Surgery (Dentist)
- Greenwich, CT
National Provider Identifier
1215929286
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Oral and Maxillofacial Surgery (Dentist)
- License
- 009275
- Practice address
- 49 Lake Ave
Greenwich, CT 06830-4501 - Phone
- (203) 661-4231
- Fax
- (203) 661-0155
- NPI assigned
- Aug 16, 2005
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 4
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Oral and Maxillofacial Surgery (Dentist) | 1223S0112X | 009275 | CT | Primary |
| Oral & Maxillofacial Surgery (D.M.D.) | 204E00000X | 042206 | CT | |
| Oral and Maxillofacial Surgery (Dentist) | 1223S0112X | 050181 | NY | |
| Oral & Maxillofacial Surgery (D.M.D.) | 204E00000X | 231685 | NY |
Addresses
Primary practice location
49 Lake Ave
Greenwich, CT 06830-4501
Mailing address
49 Lake Ave
Greenwich, CT 06830-4501
Phone (203) 661-4231
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 001422063 | Medicaid | CT |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in CT
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20050120000772 | CT | Practitioner - Maxillofacial Surgery | 4880643436 | Reassigns benefits to 1 organization |
Care Compare profile
Medicare Care Compare- Specialty
- Maxillofacial Surgery
- Education
- Rutgers New Jersey Medical School, 2001
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
Practice addresses (Care Compare)
49 Lake Ave
Suite LL4
Greenwich, CT 06830-4501
Phone (203) 661-4231
Hospital & facility affiliations
- Geisinger Medical Center
Procedures performed for Medicare patients
| Procedure | Number of procedures |
|---|---|
| Removal of tissue | 1-10 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 009275 | CT | MD | Oral and Maxillofacial Surgery (Dentist) |
| 042206 | CT | MD | Oral & Maxillofacial Surgery (D.M.D.) |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Center for Oral and Implant Surgery of Greenwich, LLC | Current | Accepting new patients | |
| Raymond Sekiguchi M.D., P.C. | Past | Accepting new patients |
Locations
49 Lake Ave
Greenwich, CT 06830
Phone (203) 661-9383
49 Lake Ave
Ste LL4
Greenwich, CT 06830
Phone (203) 552-9037
Organizations & group practices 2
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.
-
- Oral and Maxillofacial Surgery Clinic/Center
- Greenwich, CT
- NPI 1194053942
CT
-
- Family Medicine Physician
- Greenwich, CT
- NPI 1326211244
Hospital & facility affiliations 26
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": "1124150400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1344384000000",
"number": "1215929286",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "49 LAKE AVE",
"city": "GREENWICH",
"state": "CT",
"postal_code": "068304501",
"telephone_number": "203-661-4231",
"fax_number": "203-661-0155"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "49 LAKE AVE",
"city": "GREENWICH",
"state": "CT",
"postal_code": "068304501",
"telephone_number": "203-661-4231",
"fax_number": "203-661-0155"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BERGEN",
"first_name": "MICHELE",
"middle_name": "SHOSHANA",
"name_prefix": "Dr.",
"credential": "D.M.D., M.D.",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2005-08-16",
"last_updated": "2012-08-08",
"status": "A"
},
"taxonomies": [
{
"code": "1223S0112X",
"taxonomy_group": "",
"desc": "Dentist, Oral and Maxillofacial Surgery",
"state": "CT",
"license": "009275",
"primary": true
},
{
"code": "204E00000X",
"taxonomy_group": "",
"desc": "Oral & Maxillofacial Surgery",
"state": "CT",
"license": "042206",
"primary": false
},
{
"code": "1223S0112X",
"taxonomy_group": "",
"desc": "Dentist, Oral and Maxillofacial Surgery",
"state": "NY",
"license": "050181",
"primary": false
},
{
"code": "204E00000X",
"taxonomy_group": "",
"desc": "Oral & Maxillofacial Surgery",
"state": "NY",
"license": "231685",
"primary": false
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "001422063",
"state": "CT"
}
],
"endpoints": [],
"other_names": []
}Other providers in Greenwich, CT
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 8, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.