Basic Information
| Provider Information | |||||||||
| NPI: | 1437100260 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERTUS | ||||||||
| FirstName: | RONDA | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 121 N 20TH ST | ||||||||
| Address2: | # 18 P.O. BOX 2125 | ||||||||
| City: | OPELIKA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 368015449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347498303 | ||||||||
| FaxNumber: | 3347498269 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 N 20TH ST | ||||||||
| Address2: | #18 | ||||||||
| City: | OPELIKA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 368015449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347498303 | ||||||||
| FaxNumber: | 3347498269 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 04/29/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA312 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 51002842 | 01 | AL | BLUE CROSS & BLUE SHIELD | OTHER |