Healthcare Provider Details

I. General information

NPI: 1104036854
Provider Name (Legal Business Name): RHETT BERGERON M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: RHETT L. BERGERON M.D.

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 12/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 SUN VALLEY DR SUITE D
ROSWELL GA
30076-5622
US

IV. Provider business mailing address

555 SUN VALLEY D SUITE D
ROSWELL GA
30076-5622
US

V. Phone/Fax

Practice location:
  • Phone: 678-990-5401
  • Fax: 678-900-5405
Mailing address:
  • Phone: 678-990-5401
  • Fax: 678-900-5405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number044683
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number044683
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number044683
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number044683
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License Number044683
License Number StateGA
# 6
Primary TaxonomyN
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License Number044683
License Number StateGA
# 7
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number044683
License Number StateGA
# 8
Primary TaxonomyN
Taxonomy Code2081N0008X
TaxonomyNeuromuscular Medicine (Physical Medicine & Rehabilitation) Physician
License Number044683
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: