Healthcare Provider Details

I. General information

NPI: 1619880507
Provider Name (Legal Business Name): PAUL G BERTOLOTTI JR. PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1915 RANDOLPH RD
CHARLOTTE NC
28207-1101
US

IV. Provider business mailing address

2544 WEDDINGTON AVE APT 2227
CHARLOTTE NC
28204-1003
US

V. Phone/Fax

Practice location:
  • Phone: 516-302-5272
  • Fax:
Mailing address:
  • Phone: 516-302-5272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberA8943
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: