Provider Demographics
NPI:1184669517
Name:BERTEL, CHARLES KENDALL
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:KENDALL
Last Name:BERTEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 MAPLE LN STE 1
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806-3610
Mailing Address - Country:US
Mailing Address - Phone:715-685-7500
Mailing Address - Fax:
Practice Address - Street 1:1615 MAPLE LN STE 1
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-3610
Practice Address - Country:US
Practice Address - Phone:715-685-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN28487208600000X
WI52179208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN755288200Medicaid
MN029000906Medicare PIN
D48407Medicare UPIN