Provider Demographics
NPI:1205876513
Name:BERTRAM, SPENCER THOMAS (MD)
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:THOMAS
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 1:9909 KINGSTON RDG
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48348-4190
Mailing Address - Country:US
Mailing Address - Phone:108-964-5726
Mailing Address - Fax:
Practice Address - Street 1:555 W WACKERLY ST
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-4722
Practice Address - Country:US
Practice Address - Phone:989-832-4202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ5156207LP2900X
MI4301085355208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI01005987OtherHEALTH PLUS
1338919OtherAETNA
MI502512712OtherBCBSM
MI4922435-10Medicaid
P00379788OtherRAILROAD MEDICARE
MI156785OtherGREAT LAKES HEALTH PLAN
MI1023407OtherMCLAREN HEALTH PLAN
MIN98030003Medicare PIN
1338919OtherAETNA