Healthcare Provider Details

I. General information

NPI: 1366808701
Provider Name (Legal Business Name): KIRBY JO BERTRAM ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2016
Last Update Date: 01/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6262 VETERANS PARKWAY
COLUMBUS GA
31909
US

IV. Provider business mailing address

6600 KITTEN LAKE DRIVE APT 1021
MIDLAND GA
31820
US

V. Phone/Fax

Practice location:
  • Phone: 706-324-6661
  • Fax:
Mailing address:
  • Phone: 605-842-6082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT002803
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: