Basic Information
| Provider Information | |||||||||
| NPI: | 1376576124 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHEN | ||||||||
| FirstName: | BERT | ||||||||
| MiddleName: | TSI | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1930 BRANNAN RD | ||||||||
| Address2: | |||||||||
| City: | MCDONOUGH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302534310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782844040 | ||||||||
| FaxNumber: | 6782844076 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 SIGMAN RD NE STE 250A | ||||||||
| Address2: | |||||||||
| City: | CONYERS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300123812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707609900 | ||||||||
| FaxNumber: | 7707601709 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 12/13/2018 | ||||||||
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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 | 208800000X | 057443 | GA | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | BC9651159 | 01 | DEA | OTHER | 468202870A | 05 | GA | MEDICAID |