Provider Demographics
NPI:1760809347
Name:BERGERON, ANDREW MICHAEL (PT, DPT)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:MICHAEL
Last Name:BERGERON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:71121 HWY 21
Practice Address - Street 2:STE D
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433
Practice Address - Country:US
Practice Address - Phone:985-898-3979
Practice Address - Fax:985-898-3981
Is Sole Proprietor?:No
Enumeration Date:2014-03-21
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08764R225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA345459YUZ5OtherMEDICARE PTAN
888953OtherOPTUM
LA345459YWWBOtherMEDICARE PTAN