Provider Demographics
NPI:1356760227
Name:TOBIAS MOELLER-BERTRAM, M.D. CORP
Entity type:Organization
Organization Name:TOBIAS MOELLER-BERTRAM, M.D. CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-783-3600
Mailing Address - Street 1:4050 AIRPORT CENTER DR
Mailing Address - Street 2:SUITE G
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92264-1216
Mailing Address - Country:US
Mailing Address - Phone:949-783-3600
Mailing Address - Fax:949-783-3602
Practice Address - Street 1:3857 BIRCH ST
Practice Address - Street 2:SUITE 605
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2616
Practice Address - Country:US
Practice Address - Phone:949-783-3600
Practice Address - Fax:949-783-3602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-08
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA80383174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1922440684Medicare PIN
CA6888120001Medicare NSC