Healthcare Provider Details

I. General information

NPI: 1255372959
Provider Name (Legal Business Name): KEITH D BORTNEM D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 04/05/2024
Certification Date: 04/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 25TH ST S STE 1
GREAT FALLS MT
59405-5183
US

IV. Provider business mailing address

1401 25TH ST S STE 1
GREAT FALLS MT
59405-5183
US

V. Phone/Fax

Practice location:
  • Phone: 406-455-3650
  • Fax: 406-731-8318
Mailing address:
  • Phone: 406-455-3650
  • Fax: 406-731-8318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number7067
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: