Basic Information
| Provider Information | |||||||||
| NPI: | 1508325846 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | BERTI | ||||||||
| FirstName: | BRIANNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2424 S 90TH ST FL 2 | ||||||||
| Address2: | |||||||||
| City: | WEST ALLIS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532272455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143288777 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2424 S 90TH ST FL 2 | ||||||||
| Address2: | |||||||||
| City: | WEST ALLIS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532272455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143288777 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2019 | ||||||||
| LastUpdateDate: | 08/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 75252 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100172074 | 05 | WI | MEDICAID |