Provider Demographics
NPI:1477669695
Name:BERTINI, KENNETH ROBERT (RPH)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:ROBERT
Last Name:BERTINI
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6144 ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60304-2316
Mailing Address - Country:US
Mailing Address - Phone:708-383-6757
Mailing Address - Fax:708-383-6872
Practice Address - Street 1:6144 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60304-2316
Practice Address - Country:US
Practice Address - Phone:708-383-6767
Practice Address - Fax:708-383-6872
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL05400914183500000X
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL363489260001Medicaid
IL0001619516Medicare ID - Type Unspecified