Basic Information
| Provider Information | |||||||||
| NPI: | 1053730374 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BORTNEM | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9671 | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321209671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3866767130 | ||||||||
| FaxNumber: | 3866767125 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 SAINT CLAIR RIVER DR | ||||||||
| Address2: | |||||||||
| City: | ALGONAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480011802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8107944917 | ||||||||
| FaxNumber: | 8107944407 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2014 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101021159 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.