Provider Demographics
NPI:1336381243
Name:BERTSCH, STUART RANDALL
Entity Type:Individual
Prefix:
First Name:STUART
Middle Name:RANDALL
Last Name:BERTSCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 636256
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6256
Mailing Address - Country:US
Mailing Address - Phone:513-585-5502
Mailing Address - Fax:513-585-5511
Practice Address - Street 1:234 GOODMAN ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2364
Practice Address - Country:US
Practice Address - Phone:513-558-4194
Practice Address - Fax:513-558-0995
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-24
Last Update Date:2017-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR2149207L00000X
390200000X
OH35.121380207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0086018Medicaid
IN201186760Medicaid
KY7100246420Medicaid
KY7100246420Medicaid