Provider Demographics
NPI:1356502884
Name:PHILIP L BERTUCCI,MD,LLC
Entity Type:Organization
Organization Name:PHILIP L BERTUCCI,MD,LLC
Other - Org Name:STATESBORO EYEWEAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:L
Authorized Official - Last Name:BERTUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-764-7010
Mailing Address - Street 1:21 N ZETTEROWER AVE
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-7142
Mailing Address - Country:US
Mailing Address - Phone:912-764-7010
Mailing Address - Fax:912-764-5827
Practice Address - Street 1:21 N ZETTEROWER AVE
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-7142
Practice Address - Country:US
Practice Address - Phone:912-764-7010
Practice Address - Fax:912-764-5827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-18
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA435023614332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies