Provider Demographics
NPI:1366498594
Name:MCRAE-BERGERON, CHERYL E (DNP CRNA)
Entity Type:Individual
Prefix:DR
First Name:CHERYL
Middle Name:E
Last Name:MCRAE-BERGERON
Suffix:
Gender:F
Credentials:DNP CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:547 RIVERBEND RD
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30512-5971
Mailing Address - Country:US
Mailing Address - Phone:706-835-6166
Mailing Address - Fax:706-781-6949
Practice Address - Street 1:547 RIVERBEND RD
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512-5971
Practice Address - Country:US
Practice Address - Phone:706-835-6166
Practice Address - Fax:706-781-6949
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2014-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN035630367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1104009539OtherCOMPANY NPI
1336498594OtherPERSONAL NPI
800341OtherNORTH CAROLINA MEDICAID - COMPANY
8052438OtherNORTH CAROLINA MEDICAID - INDIVIDUAL
GA43ZCCCSOtherPERSONAL PTAN
GA920479139AOtherGA MEDICAID PAYEE PROVIDER NUMBER
GAGRP6628OtherPTAN CHERYL E MCRAE-BERGERON, PC
NC6391OtherMEDICAID PIN
GAGRP 6628OtherMEDICARE: COMPANY 'CHERYL E. MCRAE- BERGERON, PC' GROUP NUMBER