Healthcare Provider Details

I. General information

NPI: 1568456242
Provider Name (Legal Business Name): KIM C BERTIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 08/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 S 1100 E STE 101
SALT LAKE CITY UT
84102-1500
US

IV. Provider business mailing address

24 S 1100 E STE 101
SALT LAKE CITY UT
84102-1500
US

V. Phone/Fax

Practice location:
  • Phone: 801-355-6468
  • Fax: 801-355-3450
Mailing address:
  • Phone: 801-355-6468
  • Fax: 801-355-3450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number164111-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: