Provider Demographics
NPI:1295845444
Name:BERTOLET, BARRY DEAN (MD)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:DEAN
Last Name:BERTOLET
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 1:499 GLOSTER CREEK VLG STE A2
Mailing Address - Street 2:CARDIOLOGY ASSOCIATES OF N. MS, PA
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-4749
Mailing Address - Country:US
Mailing Address - Phone:662-620-6800
Mailing Address - Fax:662-620-6950
Practice Address - Street 1:499 GLOSTER CREEK VILLAGE A-2
Practice Address - Street 2:CARDIOLOGY ASSOCIATES OF N. MS, PA
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801
Practice Address - Country:US
Practice Address - Phone:662-620-6800
Practice Address - Fax:662-620-6950
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11333207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0118728Medicaid
MS060000224Medicare ID - Type Unspecified
MS0118728Medicaid