Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 044683 | GA |
N | 207QS0010X | Family Doctor - Sports Medicine | 044683 | GA |
N | 2081P2900X | Pain Medicine | 044683 | GA |
NPI | 1104036854 |
---|---|
Provider Name | Dr. Rhett Bergeron |
First Address | Roswell, GA 30076-5622 |
Second Address | Roswell, GA 30076-5622 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/05/2007 |
Last Update Date | 22/12/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
F89089 | (02) | GA |