1104009539 NPI number — CHERYL MCRAE-BERGERON, PC

Table of content: (NPI 1104009539)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104009539 NPI number — CHERYL MCRAE-BERGERON, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHERYL MCRAE-BERGERON, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104009539
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/11/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
547 RIVERBEND RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLAIRSVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30512-5971
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-835-6166
Provider Business Mailing Address Fax Number:
706-781-6949

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
547 RIVERBEND RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLAIRSVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30512-5971
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-835-6166
Provider Business Practice Location Address Fax Number:
706-781-6949
Provider Enumeration Date:
12/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MCRAE-BERGERON
Authorized Official First Name:
CHERYL
Authorized Official Middle Name:
ELAINE
Authorized Official Title or Position:
OWNER/OPERATOR
Authorized Official Telephone Number:
706-835-6166

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  RN035630 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 43ZCCCS . This is a "INDIVIDUAL UPIN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000550965G . This is a "GA-MEDICAID PROVIDER #" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 50BBJGS . This is a "BUSINESS UPIN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 8052438 . This is a "MA-NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: GRP6628 . This is a "MEDICARE GROUP NUMBER" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1104009539 . This is a "NPI # FOR CHERYL E. MCRAE-BERGERON, PC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1366498594 . This is a "NPI # INDIVIDUAL: CHERYL E. MCRAE-BERGERON" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 8000341 . This is a "MEDICAID-NC-GROUP" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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