1629153655 NPI number — JENNIFER S BERTRAM OT

Table of content: JENNIFER S BERTRAM OT (NPI 1629153655)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629153655 NPI number — JENNIFER S BERTRAM OT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERTRAM
Provider First Name:
JENNIFER
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
POLETE
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
S
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1629153655
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 369
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIMPSONVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29681-0369
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-329-4211
Provider Business Mailing Address Fax Number:
678-840-2112

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
213 E BUTLER RD BLDG E2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAULDIN
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29662-2172
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-346-0391
Provider Business Practice Location Address Fax Number:
678-840-2112
Provider Enumeration Date:
10/26/2006

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: 225X00000X , with the licence number:  2870 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: TH1467 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".