Provider Demographics
NPI:1114668928
Name:BERTSOS, SAMUEL T (PA)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:T
Last Name:BERTSOS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6480 HARRISON AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45247-7961
Mailing Address - Country:US
Mailing Address - Phone:513-354-3700
Mailing Address - Fax:
Practice Address - Street 1:2835 MIAMI VILLAGE DR
Practice Address - Street 2:
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342-4916
Practice Address - Country:US
Practice Address - Phone:937-354-3700
Practice Address - Fax:937-262-7468
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
OH50.007614RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant