MEDICARE: SPENCER THOMAS BERTRAM MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207LP2900X	Pain Medicine (Anesthesiology) Physician	Q5156	TX
2	208VP0014X	Interventional Pain Medicine Physician	4301085355	MI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
5	P00379788	OTHER		RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01005987	OTHER	MI	HEALTH PLUS
2	1338919	OTHER		AETNA
3	502512712	OTHER	MI	BCBSM
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	156785	OTHER	MI	GREAT LAKES HEALTH PLAN
7	1023407	OTHER	MI	MCLAREN HEALTH PLAN

General Provider Information

NPI Number	:	1205876513
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SPENCER THOMAS BERTRAM MD

Provider Business Mailing Address
First Line	:	9909 KINGSTON RDG
Second Line	:
City	:	CLARKSTON
State	:	MI
Zip	:	48348-4190
Country	:	US
Telephone Number	:	108-964-5726
Fax Number	:

Provider Business Practice Location Address
First Line	:	555 W WACKERLY ST
Second Line	:
City	:	MIDLAND
State	:	MI
Zip	:	48640-4722
Country	:	US
Telephone Number	:	989-832-4202
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2006
Last Update Date	:	01/05/2022

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Directions to “ SPENCER THOMAS BERTRAM MD” Practice Location

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