Basic Information
| Provider Information | |||||||||
| NPI: | 1013987445 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERNO | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | G. | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BERNO | ||||||||
| OtherFirstName: | MICHAEL | ||||||||
| OtherMiddleName: | G. | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 66308 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 772666308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8325485275 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6730 INDEPENDENCE BLVD | ||||||||
| Address2: | #300 | ||||||||
| City: | BAYTOWN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7133517360 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2006 | ||||||||
| LastUpdateDate: | 04/21/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | K3556 | TX | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | K3556 | TX | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 10009096 | 01 | TX | AMERIGROUP | OTHER | 080462703 | 05 | TX | MEDICAID | 143877205 | 05 | TX | MEDICAID | 82867G | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER |