Basic Information
Provider Information | |||||||||
NPI: | 1336381243 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BERTSCH | ||||||||
FirstName: | STUART | ||||||||
MiddleName: | RANDALL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 636256 | ||||||||
Address2: |   | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452636256 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5135855502 | ||||||||
FaxNumber: | 5135855511 | ||||||||
Practice Location | |||||||||
Address1: | 234 GOODMAN ST | ||||||||
Address2: |   | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452192364 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5135584194 | ||||||||
FaxNumber: | 5135580995 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/24/2009 | ||||||||
LastUpdateDate: | 05/26/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | R2149 | KY | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207L00000X | 35.121380 | OH | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 0086018 | 05 | OH |   | MEDICAID | 201186760 | 05 | IN |   | MEDICAID | 7100246420 | 05 | KY |   | MEDICAID |