Provider Demographics
NPI:1487648507
Name:BERTRAM, PHILLIP D (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:D
Last Name:BERTRAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-1726
Mailing Address - Country:US
Mailing Address - Phone:931-783-5582
Mailing Address - Fax:931-526-6760
Practice Address - Street 1:438 N WHITNEY AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2455
Practice Address - Country:US
Practice Address - Phone:931-783-2616
Practice Address - Fax:931-783-2610
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6496207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4212762OtherBCBS
TN3154324Medicaid
KY64790702Medicaid
TN31543241Medicare PIN
KY64790702Medicaid
TNB59252Medicare UPIN
TN3154326Medicaid