Provider Demographics
NPI:1104036854
Name:BERGERON, RHETT (MD)
Entity Type:Individual
Prefix:DR
First Name:RHETT
Middle Name:
Last Name:BERGERON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:RHETT
Other - Middle Name:L
Other - Last Name:BERGERON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:555 SUN VALLEY D
Mailing Address - Street 2:SUITE D
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-5622
Mailing Address - Country:US
Mailing Address - Phone:678-990-5401
Mailing Address - Fax:678-900-5405
Practice Address - Street 1:555 SUN VALLEY DR
Practice Address - Street 2:SUITE D
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-5622
Practice Address - Country:US
Practice Address - Phone:678-990-5401
Practice Address - Fax:678-900-5405
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044683207Q00000X, 207QS0010X, 261QP2300X, 2083P0500X, 2083S0010X, 2083P0011X, 2081P2900X, 2081N0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
No2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports Medicine
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No2081N0008XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationNeuromuscular Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF89089Medicare UPIN