Basic Information
| Provider Information | |||||||||
| NPI: | 1861554743 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BORTIN | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | B. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | N2950 STATE ROAD 67 | ||||||||
| Address2: | |||||||||
| City: | LAKE GENEVA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531472655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622454990 | ||||||||
| FaxNumber: | 2622452655 | ||||||||
| Practice Location | |||||||||
| Address1: | N2950 STATE ROAD 67 | ||||||||
| Address2: | |||||||||
| City: | LAKE GENEVA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531472655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622454990 | ||||||||
| FaxNumber: | 2622452655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2006 | ||||||||
| LastUpdateDate: | 08/09/2016 | ||||||||
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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 | 207RC0000X | 26253-20 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 30583300 | 05 | WI | MEDICAID |