1346360724 NPI number — MRS. PAMELA M BERTOLINO MSW

Table of content: MRS. PAMELA M BERTOLINO MSW (NPI 1346360724)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346360724 NPI number — MRS. PAMELA M BERTOLINO MSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERTOLINO
Provider First Name:
PAMELA
Provider Middle Name:
M
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1346360724
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2781 KIPLING RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FUQUAY VARINA
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27526-6169
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-586-1002
Provider Business Mailing Address Fax Number:
919-557-1018

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 MEDICAL CENTER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEBANON
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03756-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-650-5000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/30/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  C005646 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 2750 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 104100000X , with the licence number: 1018776 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6106621 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".