Basic Information
Provider Information | |||||||||
NPI: | 1770979767 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BERTINO | ||||||||
FirstName: | FREDERIC | ||||||||
MiddleName: | JOSEPH | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1405 CLIFTON RD NE | ||||||||
Address2: | DEPARTMENT OF RADIOLOGY | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 30322 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4047855437 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 560 1ST AVE | ||||||||
Address2: |   | ||||||||
City: | NEW YORK | ||||||||
State: | NY | ||||||||
PostalCode: | 100166402 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2122635230 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/07/2015 | ||||||||
LastUpdateDate: | 08/09/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/09/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 88974 | GA | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD61048424 | WA | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | MD61048424 | WA | N |   | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0204X | 88974 | GA | Y |   | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
No ID Information.