1902058126 NPI number — L. MICHAEL BERTRAM OD PLLC

Table of content: (NPI 1902058126)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902058126 NPI number — L. MICHAEL BERTRAM OD PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
L. MICHAEL BERTRAM OD PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DR. L. MICHAEL BERTRAM OD
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902058126
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/03/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
185 COMMERCIAL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VANCEBURG
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41179-6181
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-796-3295
Provider Business Mailing Address Fax Number:
606-796-9285

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
185 COMMERCIAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VANCEBURG
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41179-6181
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-796-3295
Provider Business Practice Location Address Fax Number:
606-796-9285
Provider Enumeration Date:
10/21/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BERTRAM
Authorized Official First Name:
LOUIS
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
606-796-3295

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1060DT , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 77010601 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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