Provider Demographics
NPI:1083646418
Name:BERRETTINI, WADE HAYHURST (MD)
Entity Type:Individual
Prefix:
First Name:WADE
Middle Name:HAYHURST
Last Name:BERRETTINI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3535 MARKET ST FL 3
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-3317
Mailing Address - Country:US
Mailing Address - Phone:215-746-6700
Mailing Address - Fax:
Practice Address - Street 1:3535 MARKET ST FL 3
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-3317
Practice Address - Country:US
Practice Address - Phone:215-746-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD021017E2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012197790004Medicaid
PA0012197790004Medicaid
E53260Medicare UPIN