1790857068 NPI number — MR. MARTIN F BERTRAM MD

Table of content: MR. MARTIN F BERTRAM MD (NPI 1790857068)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790857068 NPI number — MR. MARTIN F BERTRAM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERTRAM
Provider First Name:
MARTIN
Provider Middle Name:
F
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1790857068
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/13/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 337
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAYTON
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84041-0337
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-773-4840
Provider Business Mailing Address Fax Number:
801-525-8151

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1750 E 3100 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAYTON
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84040-2406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-773-4840
Provider Business Practice Location Address Fax Number:
801-525-8151
Provider Enumeration Date:
11/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  8858473-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 31164836000 . This is a "WORKERS COMP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0110963 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000038962 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com