Provider Demographics
NPI:1245455179
Name:BERNEY, BERTRAM W (MD)
Entity type:Individual
Prefix:DR
First Name:BERTRAM
Middle Name:W
Last Name:BERNEY
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 1:7524 SE MILWAUKIE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-6113
Mailing Address - Country:US
Mailing Address - Phone:503-230-4811
Mailing Address - Fax:
Practice Address - Street 1:7524 SE MILWAUKIE AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-6113
Practice Address - Country:US
Practice Address - Phone:503-230-4811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD16449207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR005079Medicaid
OR005079Medicaid
OR110400Medicare ID - Type Unspecified