Basic Information
| Provider Information | |||||||||
| NPI: | 1093706368 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERTUS | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 268919 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731268919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056083800 | ||||||||
| FaxNumber: | 4056083838 | ||||||||
| Practice Location | |||||||||
| Address1: | 4050 W MEMORIAL RD | ||||||||
| Address2: | THIRD FLOOR | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731208382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056083800 | ||||||||
| FaxNumber: | 4056083838 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2005 | ||||||||
| LastUpdateDate: | 02/17/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 861 | OK | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 861 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 10011900A | 05 | OK | MEDICAID |