1871979138 NPI number — MR. WENDY BERNARD

Table of content: MR. WENDY BERNARD (NPI 1871979138)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871979138 NPI number — MR. WENDY BERNARD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERNARD
Provider First Name:
WENDY
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
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:
1871979138
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1395 NW 167TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI GARDENS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33169-5710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-628-6117
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1190 NE 125TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33161
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-891-7500
Provider Business Practice Location Address Fax Number:
305-985-6233
Provider Enumeration Date:
08/09/2015

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: 363L00000X , with the licence number:  ARNP9276095 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4913842 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: P1035024 . This is a "FREEDOM" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 9050721 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: IJ598Y . This is a "MEDICARE (BROWARD COUNTY)" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: P01568202 . This is a "RR MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: P01793250 . This is a "SIMPLY" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: P970844 . This is a "OPTIMUM" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: QMYUD . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: IJ598Z . This is a "MEDICARE (DADE COUNTY)" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 109332500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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