Organization
LILY CREEK MEDICAL GROUP, PSC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ROBERT L. BERTRAM D.O. (PRESIDENT)
(270) 866-8881
Entity
Organization
Contact information
Practice address
92 JOE T PETTY DR, RUSSELL SPRINGS, KY 42642-8543
(270) 866-8881
(270) 866-8849
Mailing address
PO BOX 5007, FRANKFORT, KY 40602-5007
(502) 226-3858
(502) 223-9829
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
—
—
363L00000X
Nurse Practitioner
—
—
363LF0000X
Family Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000064586
ANTHEM
KY
01
—
608475500
BLACK LUNG
KY
05
—
65932386
—
KY
Enumeration date
01/15/2007
Last updated
10/30/2008
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