Provider Demographics
NPI:1679753974
Name:PENSACOLA INTERNAL MEDICINE
Entity Type:Organization
Organization Name:PENSACOLA INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTY
Authorized Official - Middle Name:W
Authorized Official - Last Name:BERTELLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-473-8575
Mailing Address - Street 1:9400 UNIVERSITY PKWY
Mailing Address - Street 2:406
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-5752
Mailing Address - Country:US
Mailing Address - Phone:850-473-8575
Mailing Address - Fax:850-473-9406
Practice Address - Street 1:9400 UNIVERSITY PKWY
Practice Address - Street 2:406
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-5752
Practice Address - Country:US
Practice Address - Phone:850-473-8575
Practice Address - Fax:850-473-9406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME47948207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH72736Medicare UPIN
FLD57092Medicare UPIN