Provider Demographics
NPI:1427153766
Name:BERTELSEN, RICHARD A JR (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:BERTELSEN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 N OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-3011
Mailing Address - Country:US
Mailing Address - Phone:417-326-6000
Mailing Address - Fax:417-328-6341
Practice Address - Street 1:1500 N OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-3011
Practice Address - Country:US
Practice Address - Phone:417-326-6000
Practice Address - Fax:417-328-6341
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO119768207R00000X
MOMD119768208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOF54534Medicare UPIN