Provider Demographics
NPI:1891808655
Name:BERTRAM, KENTON JAMES (DC)
Entity Type:Individual
Prefix:DR
First Name:KENTON
Middle Name:JAMES
Last Name:BERTRAM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:843 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-3348
Mailing Address - Country:US
Mailing Address - Phone:814-333-1277
Mailing Address - Fax:814-333-1272
Practice Address - Street 1:843 MARKET ST
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-3348
Practice Address - Country:US
Practice Address - Phone:814-333-1277
Practice Address - Fax:814-333-1272
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC-003338-L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAT-28865Medicare UPIN
PA442773Medicare PIN