Healthcare Provider Details

I. General information

NPI: 1295845444
Provider Name (Legal Business Name): BARRY DEAN BERTOLET MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 08/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

499 GLOSTER CREEK VILLAGE A-2 CARDIOLOGY ASSOCIATES OF N. MS, PA
TUPELO MS
38801
US

IV. Provider business mailing address

499 GLOSTER CREEK VLG STE A2 CARDIOLOGY ASSOCIATES OF N. MS, PA
TUPELO MS
38801-4749
US

V. Phone/Fax

Practice location:
  • Phone: 662-620-6800
  • Fax: 662-620-6950
Mailing address:
  • Phone: 662-620-6800
  • Fax: 662-620-6950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number11333
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number11333
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: