MEDICARE: LISA HEIDER BERTRAM RD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1013751197
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA HEIDER BERTRAM RD

Provider Business Mailing Address
First Line	:	2744 E FORT UNION BLVD
Second Line	:
City	:	COTTONWOOD HEIGHTS
State	:	UT
Zip	:	84121-3447
Country	:	US
Telephone Number	:	734-330-1101
Fax Number	:

Provider Business Practice Location Address
First Line	:	2744 E FORT UNION BLVD
Second Line	:
City	:	COTTONWOOD HEIGHTS
State	:	UT
Zip	:	84121-3447
Country	:	US
Telephone Number	:	734-330-1101
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2024
Last Update Date	:	04/15/2026

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