Healthcare Provider Details

I. General information

NPI: 1679586267
Provider Name (Legal Business Name): JONATHAN BERTMAN M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 MAIN ST
HOPE VALLEY RI
02832-1610
US

IV. Provider business mailing address

1111 MAIN ST
HOPE VALLEY RI
02832-1610
US

V. Phone/Fax

Practice location:
  • Phone: 401-539-0283
  • Fax: 401-539-6741
Mailing address:
  • Phone: 401-539-0283
  • Fax: 401-539-6741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberRI8814
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: