Provider Demographics
NPI:1023138419
Name:BORTOLI, MICHAEL J (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:BORTOLI
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 1:5080 SPECTRUM DR
Mailing Address - Street 2:SUITE 1200 WEST
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-4648
Mailing Address - Country:US
Mailing Address - Phone:972-364-8000
Mailing Address - Fax:214-775-4502
Practice Address - Street 1:1619 N STOUGHTON RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-2603
Practice Address - Country:US
Practice Address - Phone:615-778-4066
Practice Address - Fax:615-778-9114
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47296-0202083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIWI1447001Medicare UPIN
WIWI1448Medicare PIN
WIWI1449001Medicare UPIN
WIWI1449Medicare PIN
WIWI1447Medicare PIN
WIWI1448001Medicare UPIN