Provider Demographics
NPI:1740989573
Name:BERTRAM, GAVEN A
Entity type:Individual
Prefix:
First Name:GAVEN
Middle Name:A
Last Name:BERTRAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 KENNETH ST
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48529-2206
Mailing Address - Country:US
Mailing Address - Phone:810-766-9377
Mailing Address - Fax:
Practice Address - Street 1:2444 OAKRIDGE DR
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-6211
Practice Address - Country:US
Practice Address - Phone:810-766-9377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-01
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AS2504145673104A0625X
MIAS2504145673104A0630X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness