Provider Demographics
NPI:1477019495
Name:BERTOLINO, SCOTT JOSEPH
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:JOSEPH
Last Name:BERTOLINO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:556 PECAN ST
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-4712
Mailing Address - Country:US
Mailing Address - Phone:516-313-3606
Mailing Address - Fax:
Practice Address - Street 1:556 PECAN ST
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-4712
Practice Address - Country:US
Practice Address - Phone:516-313-3606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-14
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023827-01363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant