Provider Demographics
NPI:1689866840
Name:BERTUSO, MARY ANN (PAC)
Entity Type:Individual
Prefix:MRS
First Name:MARY ANN
Middle Name:
Last Name:BERTUSO
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1446 N RANDALL AVE
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53545-1122
Mailing Address - Country:US
Mailing Address - Phone:608-758-7215
Mailing Address - Fax:608-758-3216
Practice Address - Street 1:1969 W HART ROAD
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511
Practice Address - Country:US
Practice Address - Phone:608-758-7215
Practice Address - Fax:608-758-3216
Is Sole Proprietor?:No
Enumeration Date:2007-08-13
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1063023207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine