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General NPI Number Information
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NPI Number | 1649005620
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Entity Type | Individual
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Provider Name | MARK EDWARD BERTSCH FNP
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Gender | Male
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Dates
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Enumeration Date | 09/07/2024
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Last Update Date | 09/09/2024
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Provider Practice Location Address
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Address Line | 200 BELLE TERRE RD
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City | PORT JEFFERSON
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State | NY
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Zip | 11777-1928
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Country | US
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Telephone | 631-474-6000
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Fax |
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Provider Business Mailing Address
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Address Line | 3 NIAGARA ST
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City | MILLER PLACE
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State | NY
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Zip | 11764-2508
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Country | US
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Telephone | 631-356-3241
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 354320
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License Number State | NY
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