Basic Information
| Provider Information | |||||||||
| NPI: | 1962495895 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SY | ||||||||
| FirstName: | BERTRAND | ||||||||
| MiddleName: | OLAVIDES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2249 | ||||||||
| Address2: | |||||||||
| City: | BAY ST LOUIS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395212249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2284671820 | ||||||||
| FaxNumber: | 2284673233 | ||||||||
| Practice Location | |||||||||
| Address1: | 151 THAMES AVE | ||||||||
| Address2: | |||||||||
| City: | BAY ST LOUIS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395205002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2284671320 | ||||||||
| FaxNumber: | 2284673233 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 09048 | MS | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 00019303 | 05 | MS | MEDICAID |