Basic Information
| Provider Information | |||||||||
| NPI: | 1942815063 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERTRAM | ||||||||
| FirstName: | RILEY | ||||||||
| MiddleName: | S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12105 65TH CIR NE | ||||||||
| Address2: | |||||||||
| City: | OTSEGO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553014679 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122196180 | ||||||||
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| Practice Location | |||||||||
| Address1: | 202 SOUTH PARK STREET | ||||||||
| Address2: | 4 TOWER | ||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6084176676 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2020 | ||||||||
| LastUpdateDate: | 09/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
No ID Information.