Healthcare Provider Details

I. General information

NPI: 1942815063
Provider Name (Legal Business Name): RILEY S BERTRAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2020
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29792 ARDEN DR
GREY EAGLE MN
56336-4776
US

IV. Provider business mailing address

29792 ARDEN DR
GREY EAGLE MN
56336-4776
US

V. Phone/Fax

Practice location:
  • Phone: 612-219-6180
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number170
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number117
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: