Provider Demographics
NPI:1194415570
Name:BERGQUIST, SCOTT R
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:R
Last Name:BERGQUIST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2045 OAK MARSH DR
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-2462
Mailing Address - Country:US
Mailing Address - Phone:888-684-8227
Mailing Address - Fax:888-684-8227
Practice Address - Street 1:2045 OAK MARSH DR
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-2462
Practice Address - Country:US
Practice Address - Phone:888-684-8227
Practice Address - Fax:888-684-8227
Is Sole Proprietor?:No
Enumeration Date:2023-05-10
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor