Basic Information
| Provider Information | |||||||||
| NPI: | 1285627869 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERTRAND | ||||||||
| FirstName: | SUSAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11350 MCCORMICK RD | ||||||||
| Address2: | EXECUTIVE PLAZA 1, STE. 501 | ||||||||
| City: | HUNT VALLEY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7039148000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 251 KEISLER DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275187091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198030813 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2005 | ||||||||
| LastUpdateDate: | 07/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | 5168 | AK | N | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 2081P2900X | 5168 | AK | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | MD5212 | 05 | AK | MEDICAID | 0190956 | 01 | AK | WA DEPT OF L&I | OTHER |