=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902058126
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | L. MICHAEL BERTRAM OD PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2008
-----------------------------------------------------
Last Update Date | 10/03/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 185 COMMERCIAL DR
-----------------------------------------------------
City | VANCEBURG
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41179-6181
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-796-3295
-----------------------------------------------------
Fax | 606-796-9285
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 185 COMMERCIAL DR
-----------------------------------------------------
City | VANCEBURG
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41179-6181
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-796-3295
-----------------------------------------------------
Fax | 606-796-9285
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. LOUIS MICHAEL BERTRAM
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 606-796-3295
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1060DT
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------