Basic Information
| Provider Information | |||||||||
| NPI: | 1194720987 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERNIE | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | JEREMY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9000 N MAIN ST | ||||||||
| Address2: | SUITE 234 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454151180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372778988 | ||||||||
| FaxNumber: | 9378322421 | ||||||||
| Practice Location | |||||||||
| Address1: | 9000 N MAIN ST | ||||||||
| Address2: | SUITE 234 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454151180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372778988 | ||||||||
| FaxNumber: | 9378322421 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2005 | ||||||||
| LastUpdateDate: | 09/07/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | 35.038152 | OH | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 0332456 | 05 | OH | MEDICAID |