Provider Demographics
NPI:1386686376
Name:BARTLESON, JERRY RUSSELL (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:RUSSELL
Last Name:BARTLESON
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 1:7434 SONG LAKE RD
Mailing Address - Street 2:
Mailing Address - City:TULLY
Mailing Address - State:NY
Mailing Address - Zip Code:13159-9211
Mailing Address - Country:US
Mailing Address - Phone:315-696-5539
Mailing Address - Fax:315-696-5539
Practice Address - Street 1:7434 SONG LAKE RD
Practice Address - Street 2:
Practice Address - City:TULLY
Practice Address - State:NY
Practice Address - Zip Code:13159-9211
Practice Address - Country:US
Practice Address - Phone:315-696-5539
Practice Address - Fax:315-696-5539
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY163749207P00000X
MN31435207P00000X
WI28860207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31522700Medicaid
NY163749Medicaid
NY163749Medicaid
WI31522700Medicaid