1811991391 NPI number — MARK E BERNTHAL OD

Table of content: MARK E BERNTHAL OD (NPI 1811991391)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811991391 NPI number — MARK E BERNTHAL OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERNTHAL
Provider First Name:
MARK
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811991391
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21711 GREATER MACK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST CLAIR SHORES
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48080-2418
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-774-0393
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21711 GREATER MACK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST CLAIR SHORES
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48080-2418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-774-0393
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/13/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  4901002685 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0218080001 . This is a "DMERC" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 410016688 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".