Provider Demographics
NPI:1417008756
Name:BERTRAM, ROBERT L (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:BERTRAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 JOE T PETTY DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:RUSSELL SPRINGS
Mailing Address - State:KY
Mailing Address - Zip Code:42642-8544
Mailing Address - Country:US
Mailing Address - Phone:270-866-8881
Mailing Address - Fax:270-866-8849
Practice Address - Street 1:92 JOE T PETTY DR
Practice Address - Street 2:
Practice Address - City:RUSSELL SPRINGS
Practice Address - State:KY
Practice Address - Zip Code:42642-8543
Practice Address - Country:US
Practice Address - Phone:270-866-8881
Practice Address - Fax:270-866-8849
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02506207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY608475500OtherBLACK LUNG
KY000000064586OtherANTHEM
KY110185245OtherRAILROAD MEDICARE
KY64025067Medicaid
KY608475500OtherBLACK LUNG
KYG49997Medicare UPIN
KY0727501Medicare PIN