Provider Demographics
NPI:1609865823
Name:BERTKA, KENNETH R (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:BERTKA
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 1:2830 EASTON AVE
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18017-4204
Mailing Address - Country:US
Mailing Address - Phone:484-526-3555
Mailing Address - Fax:484-526-3560
Practice Address - Street 1:2830 EASTON AVE
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18017-4204
Practice Address - Country:US
Practice Address - Phone:484-526-3555
Practice Address - Fax:484-526-3560
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35050904207Q00000X
WI65395207Q00000X
PAMD460346207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0631472Medicaid
WI1609865823Medicaid
WI1609865823Medicaid