Provider Demographics
NPI:1366808701
Name:BERTRAM, KIRBY JO (ATC)
Entity type:Individual
Prefix:
First Name:KIRBY
Middle Name:JO
Last Name:BERTRAM
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 KITTEN LAKE DRIVE
Mailing Address - Street 2:APT 1021
Mailing Address - City:MIDLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31820
Mailing Address - Country:US
Mailing Address - Phone:605-842-6082
Mailing Address - Fax:
Practice Address - Street 1:6262 VETERANS PARKWAY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909
Practice Address - Country:US
Practice Address - Phone:706-324-6661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-14
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0028032255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer