1255963104 NPI number — GREGORY LAWRENCE BERTRAM L.AC.

Table of content: JOHN D ANDRAKO M.D. (NPI 1366412199)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255963104 NPI number — GREGORY LAWRENCE BERTRAM L.AC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERTRAM
Provider First Name:
GREGORY
Provider Middle Name:
LAWRENCE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
L.AC.
Provider Gender Code:
M

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:
1255963104
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
131 POST RD E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTPORT
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06880-3410
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
131 POST RD E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESTPORT
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06880-3410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-226-2682
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/09/2020

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: 171100000X , with the licence number:  000481 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com