Provider Demographics
NPI:1811352446
Name:TOBIAS MOELLER-BERTRAM, MD CORPORATION
Entity type:Organization
Organization Name:TOBIAS MOELLER-BERTRAM, MD CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TOBIAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MOELLER-BERTRAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-783-3600
Mailing Address - Street 1:3857 BIRCH ST
Mailing Address - Street 2:#605
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2616
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:36101 BOB HOPE DR
Practice Address - Street 2:STE B-2
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-2001
Practice Address - Country:US
Practice Address - Phone:760-321-1315
Practice Address - Fax:760-321-1094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-28
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26426367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty