Provider Demographics
NPI:1235180944
Name:BERTSCH, THOMAS WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:WAYNE
Last Name:BERTSCH
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:PO BOX 388
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-0388
Mailing Address - Country:US
Mailing Address - Phone:916-771-6764
Mailing Address - Fax:
Practice Address - Street 1:4600 BROADWAY
Practice Address - Street 2:STE 1300
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95820
Practice Address - Country:US
Practice Address - Phone:916-874-9823
Practice Address - Fax:916-874-2689
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY192363207R00000X
CAG86836207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Not Answered207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
I38561Medicare UPIN