| Doctor Name: | DR. JACQUELINE MAIDA BERGDOLL |
| NPI Number: | 1174749717 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | M.D. |
| License Number: | 4301077244 |
| Business Practice Address: | 30 Uchee Pines Rd Lot 75 Seale, AL - 368755726 |
| Business Phone Number: | 3348554764 |
| Business Fax Number: | 3348559014 |
| Mailing Address: | 30 Uchee Pines Rd Lot 61, SEALE |
| State: | AL |
| Postal Code: | 368755734 |
| Phone Number: | 3348554765 |
| Fax Number: | 3348559014 |
| NPI Enumeration Date: | 04/18/2007 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 208D00000X |
| License Number: | 4301077244 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MI |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | General Practice |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |