Healthcare Provider Details

I. General information

NPI: 1104886662
Provider Name (Legal Business Name): CHARLES A BERGSTROM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 12/30/2021
Certification Date: 12/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 NORTH PARK DR.
FAYETTEVILLE GA
30214
US

IV. Provider business mailing address

108 N PARK DR
FAYETTEVILLE GA
30214-1645
US

V. Phone/Fax

Practice location:
  • Phone: 770-461-3466
  • Fax: 770-461-3884
Mailing address:
  • Phone: 770-461-3466
  • Fax: 770-461-3884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number033030
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number033030
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: