Basic Information
| Provider Information | |||||||||
| NPI: | 1063803930 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERTRAND | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | DAVID | ||||||||
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| Mailing Information | |||||||||
| Address1: | 402 S SILVER SPRINGS RD | ||||||||
| Address2: | |||||||||
| City: | CAPE GIRARDEAU | ||||||||
| State: | MO | ||||||||
| PostalCode: | 637037536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733322779 | ||||||||
| FaxNumber: | 5736514345 | ||||||||
| Practice Location | |||||||||
| Address1: | 820 PARK DR | ||||||||
| Address2: | |||||||||
| City: | STE GENEVIEVE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 636701566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738837407 | ||||||||
| FaxNumber: | 5738837537 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2015 | ||||||||
| LastUpdateDate: | 02/12/2015 | ||||||||
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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 | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.