Healthcare Provider Details

I. General information

NPI: 1053730374
Provider Name (Legal Business Name): JASON R BORTNEM DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2014
Last Update Date: 07/21/2022
Certification Date: 02/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 SAINT CLAIR RIVER DR
ALGONAC MI
48001-1802
US

IV. Provider business mailing address

PO BOX 9671
DAYTONA BEACH FL
32120-9671
US

V. Phone/Fax

Practice location:
  • Phone: 810-794-4917
  • Fax: 810-794-4407
Mailing address:
  • Phone: 386-676-7130
  • Fax: 386-676-7125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101021159
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: