Provider Demographics
NPI:1366441248
Name:MAURO-BERTOLO, MARY (PT)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:MAURO-BERTOLO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6221 RTE 31 STE 103
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:NY
Mailing Address - Zip Code:13039
Mailing Address - Country:US
Mailing Address - Phone:315-699-1009
Mailing Address - Fax:315-699-1094
Practice Address - Street 1:6221 RTE 31 STE 103
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:NY
Practice Address - Zip Code:13039
Practice Address - Country:US
Practice Address - Phone:315-699-1009
Practice Address - Fax:315-699-1094
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007911-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
R55621Medicare UPIN
NY56332CMedicare ID - Type Unspecified