Provider Demographics
NPI:1104886662
Name:BERGSTROM, CHARLES A (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:A
Last Name:BERGSTROM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:108 N PARK DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-1645
Mailing Address - Country:US
Mailing Address - Phone:770-461-3466
Mailing Address - Fax:770-461-3884
Practice Address - Street 1:108 NORTH PARK DR.
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214
Practice Address - Country:US
Practice Address - Phone:770-461-3466
Practice Address - Fax:770-461-3884
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA033030174400000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1104886662OtherNPI
GA52030615OtherBCBS OF GA
GA52030615OtherBCBS OF GA
GA08BDBZTMedicare ID - Type Unspecified