Provider Demographics
NPI:1427174549
Name:JENNETTE BERGSTEDT MD LLC
Entity type:Organization
Organization Name:JENNETTE BERGSTEDT MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNETTE
Authorized Official - Middle Name:SEPULVADO
Authorized Official - Last Name:BERGSTEDT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-474-2933
Mailing Address - Street 1:4150 NELSON RD STE E1
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-4133
Mailing Address - Country:US
Mailing Address - Phone:337-474-2933
Mailing Address - Fax:337-474-5283
Practice Address - Street 1:4150 NELSON RD STE E1
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4133
Practice Address - Country:US
Practice Address - Phone:337-474-2933
Practice Address - Fax:337-474-5283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.021307261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1655724Medicaid
LAF96555Medicare UPIN
LA5U957Medicare ID - Type Unspecified