Basic Information
| Provider Information | |||||||||
| NPI: | 1992896401 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERGQUIST | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 400 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383020400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7314238697 | ||||||||
| FaxNumber: | 7314225743 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 SKYLINE DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383013923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7314238697 | ||||||||
| FaxNumber: | 7314225743 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 06/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 29315 | TN | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207R00000X | MD29631 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3000510 | 05 | TN | MEDICAID | P00694508 | 01 | TN | RR MEDICARE | OTHER |