Provider Demographics
NPI:1790857068
Name:BERTRAM, MARTIN F (MD)
Entity Type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:F
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 1:4960 MIDDLE URBANA RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503
Mailing Address - Country:US
Mailing Address - Phone:937-399-8366
Mailing Address - Fax:937-399-8379
Practice Address - Street 1:4960 MIDDLE URBANA RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503
Practice Address - Country:US
Practice Address - Phone:937-399-8366
Practice Address - Fax:937-399-8379
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35067942208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000038962OtherBCBS
OH0110963Medicaid
31164836000OtherWORKERS COMP
OH0110963Medicaid
0775999Medicare PIN