Basic Information
| Provider Information | |||||||||
| NPI: | 1184785008 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERTRAM | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | ALAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1330 INTERSTATE PKWY | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309095625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066512020 | ||||||||
| FaxNumber: | 7068556674 | ||||||||
| Practice Location | |||||||||
| Address1: | 1330 INTERSTATE PKWY | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309095625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066512020 | ||||||||
| FaxNumber: | 7068556674 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 05/28/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 030011 | GA | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 1977325 | 01 | CIGNA | OTHER | 000389958E | 05 | GA | MEDICAID | 18BDFMJ | 01 | GA | PTAN | OTHER | 4363115 | 01 | AETNA | OTHER | 768090 | 01 | GA | BLUE CROSS OF GEORGIA | OTHER |