1134424005 NPI number — REONO BERTAGNOLLI A MEDICAL GROUP

Table of content: (NPI 1134424005)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134424005 NPI number — REONO BERTAGNOLLI A MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REONO BERTAGNOLLI A MEDICAL GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1134424005
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/18/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
930 RIDGEBROOK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPARKS
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21152-9481
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-786-8015
Provider Business Mailing Address Fax Number:
410-472-1754

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10948 BIGGE ST STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN LEANDRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94577-1121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-786-8015
Provider Business Practice Location Address Fax Number:
410-472-1754
Provider Enumeration Date:
01/24/2011

Additional Information

Authorized Official

Authorized Official Last Name:
CUOMO
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
C
Authorized Official Title or Position:
AUTHORIZED OFFICIAL, CFO
Authorized Official Telephone Number:
800-786-8015

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 229204100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: GP7919 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 103122841-0002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1134424005 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1134424005 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201331960A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1134424005 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 281984 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 371391901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003144608A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0347620 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1134424005 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1134424005 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1134424005 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1134424005 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1134424005 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0695921 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1134424005 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1134424005 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1134424005 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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