Provider Demographics
NPI:1023469681
Name:BERTUCCI, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BERTUCCI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 PRYTANIA ST
Mailing Address - Street 2:STE 35
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70115-3678
Mailing Address - Country:US
Mailing Address - Phone:504-897-8412
Mailing Address - Fax:504-249-5311
Practice Address - Street 1:1401 FOUCHER ST FL 2
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70115-3515
Practice Address - Country:US
Practice Address - Phone:504-210-4472
Practice Address - Fax:504-210-4473
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-24
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMMD.39911LL207Q00000X
LA320671208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2533223Medicaid