Provider Demographics
NPI:1194754622
Name:BERTRAM, MICHAEL J (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
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 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-957-0052
Mailing Address - Fax:859-957-0054
Practice Address - Street 1:651 CENTRE VIEW BLVD
Practice Address - Street 2:
Practice Address - City:CRESTVIEW HILLS
Practice Address - State:KY
Practice Address - Zip Code:41017-5423
Practice Address - Country:US
Practice Address - Phone:859-578-5665
Practice Address - Fax:859-331-0012
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-084075208100000X
IN01065012A208VP0014X
OH35084075208VP0014X
KY49097208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64083579Medicaid
IN7818551OtherAETNA
IN200368460Medicaid
IN000000568635OtherANTHEM
OH2470580Medicaid
OH2470580Medicaid
IN218940CMedicare PIN
OHP00834111Medicare PIN
OHBE4144654Medicare PIN
IN000000568635OtherANTHEM
IN200368460Medicaid