Provider Demographics
NPI:1699081356
Name:GIANCARLO BERTOZZI MD PA
Entity type:Organization
Organization Name:GIANCARLO BERTOZZI MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/SURGEON/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GIANCARLO
Authorized Official - Middle Name:
Authorized Official - Last Name:BERTOZZI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-396-2421
Mailing Address - Street 1:3599 UNIVERSITY BLVD S STE 802
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4258
Mailing Address - Country:US
Mailing Address - Phone:904-396-2421
Mailing Address - Fax:904-398-1854
Practice Address - Street 1:3599 UNIVERSITY BLVD S STE 802
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4258
Practice Address - Country:US
Practice Address - Phone:904-396-2421
Practice Address - Fax:904-398-1854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-19
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 20514208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL054722100Medicaid
FL16933Medicare PIN
FLD67142Medicare UPIN