Charles A Bergstrom, M.D.
Individual provider Active NPI Family Medicine Physician · Fayetteville, GA
NPI 1104886662 · NPPES record last updated Dec 30, 2021
Key facts
- NPI
- 1104886662
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Family Medicine Physician 207Q00000X
- License
- 033030 (GA)
- Practice address
- 108 North Park Dr.
Fayetteville, GA 30214 - Phone
- (770) 461-3466
- Fax
- (770) 461-3884
- NPI assigned
- Mar 27, 2006
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 3
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in GA
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20110112000493 | GA | Practitioner - Family Practice | 0244429876 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 033030 | GA | MD | Specialist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Privia Medical Group of Georgia LLC | Family Medicine | Current |
Accepting new patients |
| PMC Long Term Care, LLC | Current |
Accepting new patients | |
| Privia Medical Group of Georgia LLC | Family Medicine | Current |
Accepting new patients |
Locations
101 Yorktown Dr
Ste 100
Fayetteville, GA 30214
Phone (770) 460-4285
108 N Park Dr
Fayetteville, GA 30214
Phone (770) 461-3466
190 Greencastle Rd
#2
Tyrone, GA 30290
Phone (770) 487-7807
Interoperability endpoints
- https://api.platform.athenahealth.com/8042/brand/1/csg/1/fhir/r4
- charles.bergstrom@ffp.trimed.direct-ci.com
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Specialist | 174400000X | 033030 | GA | |
| Family Medicine Physician | 207Q00000X | 033030 | GA | Yes |
Addresses
Primary practice location
108 North Park Dr.
Fayetteville, GA 30214
Mailing address
108 N Park Dr
Fayetteville, GA 30214-1645
Phone (770) 461-3466
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1104886662 | Other | GA | NPI |
| 52030615 | Other | GA | BCBS OF GA |
Other providers in Fayetteville, GA
- Monica Renee Bennett
- Stephanie Bennette
- Deborah Bentley
- Stacey Bentley
- Larry Bergere
- Tashinea Bernadin
- Nicketa Bernard
- Andrew Bernstein
- Jasmine Berry
- Brittney Besley
All providers in Fayetteville, GA · Family Medicine Physician in Georgia
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Dec 30, 2021. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.