Healthcare Provider Details

I. General information

NPI: 1962708081
Provider Name (Legal Business Name): DR. GIANLUCA BERTOLIZIO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2011
Last Update Date: 02/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 TUPPER STREET ROOM C-1118
MONTREAL QUEBEC
H3H 1P3
CA

IV. Provider business mailing address

2300 TUPPER STREET ROOM C-1118
MONTREAL QUEBEC
H3H 1P3
CA

V. Phone/Fax

Practice location:
  • Phone: 514-586-2674
  • Fax: 514-412-4341
Mailing address:
  • Phone: 514-586-2674
  • Fax: 514-412-4341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number07274
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: