Provider Demographics
NPI:1578566352
Name:BERGERON, GLYNN A (MD)
Entity Type:Individual
Prefix:DR
First Name:GLYNN
Middle Name:A
Last Name:BERGERON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 14416
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31416-1416
Mailing Address - Country:US
Mailing Address - Phone:912-355-8200
Mailing Address - Fax:912-356-6967
Practice Address - Street 1:6 WHEELER CT
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-5719
Practice Address - Country:US
Practice Address - Phone:912-355-8200
Practice Address - Fax:912-356-6967
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA194822085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00153029AMedicaid
GA003681OtherBLUE CROSS BLUE SHIELD
GAE97657Medicare UPIN
GA30CDBPJMedicare ID - Type Unspecified