MEDICARE: SUZANNE M. BERTOLLO M.D., MPH

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	207P00000X	Emergency Medicine Physician	ME144621	FL
2	207P00000X	Emergency Medicine Physician	9700023	NC
3	207P00000X	Emergency Medicine Physician	30296	SC
4	2083P0901X	Public Health & General Preventive Medicine Physician	ME144621	FL
5	2083P0901X	Public Health & General Preventive Medicine Physician	30296	SC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AA22522353	OTHER	SC	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871542902
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUZANNE M. BERTOLLO M.D., MPH

Provider Business Mailing Address
First Line	:	777 GLADES RD # BC-71
Second Line	:
City	:	BOCA RATON
State	:	FL
Zip	:	33431-6424
Country	:	US
Telephone Number	:	561-297-3622
Fax Number	:

Provider Business Practice Location Address
First Line	:	777 GLADES RD # BC71
Second Line	:
City	:	BOCA RATON
State	:	FL
Zip	:	33431-6424
Country	:	US
Telephone Number	:	561-297-3622
Fax Number	:

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

Provider Enumeration Date	:	05/08/2006
Last Update Date	:	06/28/2021

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