Healthcare Provider Details

I. General information

NPI: 1871542902
Provider Name (Legal Business Name): SUZANNE M. BERTOLLO M.D., MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 06/28/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 GLADES RD # BC71
BOCA RATON FL
33431-6424
US

IV. Provider business mailing address

777 GLADES RD # BC-71
BOCA RATON FL
33431-6424
US

V. Phone/Fax

Practice location:
  • Phone: 561-297-3622
  • Fax:
Mailing address:
  • Phone: 561-297-3622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberME144621
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number9700023
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number30296
License Number StateSC
# 4
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberME144621
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number30296
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: