MEDICARE: CHARLES NORMAN BERTOIA O.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0040031350	OTHER	IL	BCBS PROVIDER #

General Provider Information

NPI Number	:	1427065671
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES NORMAN BERTOIA O.D

Provider Business Mailing Address
First Line	:	1716 HIGHLAND AVE
Second Line	:
City	:	WILMETTE
State	:	IL
Zip	:	60091-2412
Country	:	US
Telephone Number	:	847-707-8565
Fax Number	:	312-236-3825

Provider Business Practice Location Address
First Line	:	70 E LAKE ST # 107
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60601-5959
Country	:	US
Telephone Number	:	312-236-3822
Fax Number	:	312-236-3825

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/01/2006
Last Update Date	:	07/08/2007

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