Basic Information
| Provider Information | |||||||||
| NPI: | 1093770570 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERTRAM | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | TIMOTHY | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 705 BUTTERMILK PIKE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CRESCENT SPRINGS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410171303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593413937 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 705 BUTTERMILK PIKE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CRESCENT SPRINGS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410171303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593413937 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 02/09/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1569DT | KY | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 77000974 | 05 | KY | MEDICAID |