Provider Demographics
NPI:1427125558
Name:BERTACCHI & ASSOCIATES, PC
Entity type:Organization
Organization Name:BERTACCHI & ASSOCIATES, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:LA ROY
Authorized Official - Last Name:BERTACCHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-359-2042
Mailing Address - Street 1:276 HIGH RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-3013
Mailing Address - Country:US
Mailing Address - Phone:203-359-2042
Mailing Address - Fax:203-359-2082
Practice Address - Street 1:276 HIGH RIDGE RD
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-3013
Practice Address - Country:US
Practice Address - Phone:203-359-2042
Practice Address - Fax:203-359-2082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0340332081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC03151OtherMEDICARE GROUP NUMBER