Provider Demographics
NPI:1407848864
Name:BERTOLETTE, BARRY LEE (NP)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:LEE
Last Name:BERTOLETTE
Suffix:
Gender:M
Credentials:NP
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 1418
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28151-1418
Mailing Address - Country:US
Mailing Address - Phone:704-480-1882
Mailing Address - Fax:704-480-1832
Practice Address - Street 1:618 NORTH MORGAN STREET
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-4439
Practice Address - Country:US
Practice Address - Phone:704-480-1882
Practice Address - Fax:704-480-1832
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201451363LP0808X, 363LP2300X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6605025Medicaid
NC89014FPMedicaid
NC2592175Medicare ID - Type Unspecified
NCP00158969Medicare ID - Type UnspecifiedRR
NC2329433Medicare UPIN
NC6605025Medicaid