Provider Demographics
NPI:1841624582
Name:TOBIAS MOELLER-BERTRAM,MD CORPORATION
Entity type:Organization
Organization Name:TOBIAS MOELLER-BERTRAM,MD CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TOBIAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MOELLER-BERTRAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-317-5790
Mailing Address - Street 1:3857 BIRCH ST
Mailing Address - Street 2:SUITE 605
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2616
Mailing Address - Country:US
Mailing Address - Phone:949-783-3600
Mailing Address - Fax:949-783-3602
Practice Address - Street 1:36101 BOB HOPE DR
Practice Address - Street 2:SUITE B2
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-2001
Practice Address - Country:US
Practice Address - Phone:760-347-7676
Practice Address - Fax:760-321-1094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-29
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD16880207LP2900X
CAA80383207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA80383AMedicare PIN