1366441925 NPI number — GLENN IRA BERNSTEIN MD

Table of content: GLENN IRA BERNSTEIN MD (NPI 1366441925)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366441925 NPI number — GLENN IRA BERNSTEIN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERNSTEIN
Provider First Name:
GLENN
Provider Middle Name:
IRA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1366441925
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 278
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODBURN
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97071
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
971-983-5333
Provider Business Mailing Address Fax Number:
971-983-5326

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
406 WELCH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SILVERTON
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97381
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-873-8853
Provider Business Practice Location Address Fax Number:
503-873-8355
Provider Enumeration Date:
07/18/2005

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: 207V00000X , with the licence number:  37327 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: MD160464 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4068112 . This is a "BLUE CROSS OF TN" identifier . This identifiers is of the category "OTHER".




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