Provider Demographics
NPI:1255372959
Name:BORTNEM, KEITH D (DO)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:D
Last Name:BORTNEM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 25TH ST S STE 1
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-5183
Mailing Address - Country:US
Mailing Address - Phone:406-455-3650
Mailing Address - Fax:406-731-8318
Practice Address - Street 1:1401 25TH ST S STE 1
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-5183
Practice Address - Country:US
Practice Address - Phone:406-455-3650
Practice Address - Fax:406-731-8318
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT7067207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
000003721OtherBLUE CROSS BLUE SHIELD
0206209OtherWASHINGTON L&I
MT0094796Medicaid
MT200012385OtherRAILROAD MEDICARE
MT810347861003OtherEBMS
MT810347861OtherCHAMPUS
0206209OtherWASHINGTON L&I
MT810347861OtherCHAMPUS
MT010000372Medicare PIN