Provider Demographics
NPI:1447281662
Name:BERGSMA, CORWYN B (DPM)
Entity type:Individual
Prefix:
First Name:CORWYN
Middle Name:B
Last Name:BERGSMA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4540 KALAMAZOO AVE SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-4625
Mailing Address - Country:US
Mailing Address - Phone:616-281-0666
Mailing Address - Fax:616-281-0752
Practice Address - Street 1:1195 WILSON AVE NW
Practice Address - Street 2:SUITE 200
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49534-6405
Practice Address - Country:US
Practice Address - Phone:616-453-8277
Practice Address - Fax:616-453-2002
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002157213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1266510001OtherADMINISTAR
MI4584211Medicaid
MI480026386OtherRAILROAD MEDICARE
MI4584211Medicaid
MIU98570Medicare UPIN