Provider Demographics
NPI:1669411096
Name:BERTRAM, RONALD (MD)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:
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:PO BOX 550
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745-0550
Mailing Address - Country:US
Mailing Address - Phone:479-463-7775
Mailing Address - Fax:479-463-7187
Practice Address - Street 1:3000 NW A ST
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-3985
Practice Address - Country:US
Practice Address - Phone:479-268-3050
Practice Address - Fax:479-273-0050
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE3360207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR148406001Medicaid
ARH68163Medicare UPIN
AR148406001Medicaid