Basic Information
| Provider Information | |||||||||
| NPI: | 1871542902 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERTOLLO | ||||||||
| FirstName: | SUZANNE | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | M.D., MPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 777 GLADES RD # BC-71 | ||||||||
| Address2: | |||||||||
| City: | BOCA RATON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334316424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5612973622 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 777 GLADES RD # BC71 | ||||||||
| Address2: | |||||||||
| City: | BOCA RATON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334316424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5612973622 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 06/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | ME144621 | FL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 9700023 | NC | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 30296 | SC | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 2083P0901X | ME144621 | FL | Y | Allopathic & Osteopathic Physicians | Preventive Medicine | Public Health & General Preventive Medicine | 2083P0901X | 30296 | SC | N | Allopathic & Osteopathic Physicians | Preventive Medicine | Public Health & General Preventive Medicine |
ID Information
| ID | Type | State | Issuer | Description | AA22522353 | 01 | SC | MEDICARE PTAN | OTHER | N00023 | 05 | SC | MEDICAID | 79-10976 | 05 | NC | MEDICAID |