Provider Demographics
NPI:1487790655
Name:BERTCH, MARK (PT, DPT, OCS, CSCS)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BERTCH
Suffix:
Gender:M
Credentials:PT, DPT, OCS, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16101 EVANS ST.
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68116
Mailing Address - Country:US
Mailing Address - Phone:402-717-0009
Mailing Address - Fax:402-717-0011
Practice Address - Street 1:16101 EVANS ST.
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68116
Practice Address - Country:US
Practice Address - Phone:402-717-0009
Practice Address - Fax:402-717-0011
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2256225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025768700Medicaid
NE098899Medicare PIN