Healthcare Provider Details

I. General information

NPI: 1134319486
Provider Name (Legal Business Name): CRAIG S BERTELSEN PT, CERT MDT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2007
Last Update Date: 03/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 HIGHWAY 45
BALDWYN MS
38824-8591
US

IV. Provider business mailing address

PO BOX 366 715 HWY 45
BALDWYN MS
38824-0366
US

V. Phone/Fax

Practice location:
  • Phone: 662-365-5610
  • Fax: 662-365-5611
Mailing address:
  • Phone: 662-365-5610
  • Fax: 662-365-5611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT2339
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: