Provider Demographics
NPI:1295324937
Name:BERTSCH, MADELINE DOROTHY
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:DOROTHY
Last Name:BERTSCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3378 MARINER BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609-2460
Mailing Address - Country:US
Mailing Address - Phone:352-796-7171
Mailing Address - Fax:
Practice Address - Street 1:3378 MARINER BLVD
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34609-2460
Practice Address - Country:US
Practice Address - Phone:352-796-7171
Practice Address - Fax:352-556-4889
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-17
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLPA9117562363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program