Healthcare Provider Details

I. General information

NPI: 1336227628
Provider Name (Legal Business Name): KENNETH ALVIN BERTRAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1434 PORTER ST BARQUIST ARMY HEALTH CLINIC
FREDERICK MD
21702-9210
US

IV. Provider business mailing address

6704 HEIRLOOM CT
FREDERICK MD
21702-5802
US

V. Phone/Fax

Practice location:
  • Phone: 301-619-4666
  • Fax: 301-619-7676
Mailing address:
  • Phone: 301-631-9228
  • Fax: 301-319-9849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberMD00024580
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: