Basic Information
| Provider Information | |||||||||
| NPI: | 1285953695 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERGRAB | ||||||||
| FirstName: | PEGGY | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOHNSON | ||||||||
| OtherFirstName: | PEGGY | ||||||||
| OtherMiddleName: | J | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2336 DAWSON RD | ||||||||
| Address2: | SUITE 2200 | ||||||||
| City: | ALBANY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317072800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293128800 | ||||||||
| FaxNumber: | 2293128855 | ||||||||
| Practice Location | |||||||||
| Address1: | 2336 DAWSON RD | ||||||||
| Address2: | SUITE 2200 | ||||||||
| City: | ALBANY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317072800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293128800 | ||||||||
| FaxNumber: | 2293128855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2010 | ||||||||
| LastUpdateDate: | 05/25/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 064330 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.