Basic Information
| Provider Information | |||||||||
| NPI: | 1265467559 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERNDT | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 98978 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891938978 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022163346 | ||||||||
| FaxNumber: | 7026716883 | ||||||||
| Practice Location | |||||||||
| Address1: | 1447 N HARRISON ST | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486024727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9895830000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 06/25/2018 | ||||||||
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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 | 207Q00000X | 16573 | NV | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 4301068879 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4381550 | 05 | MI | MEDICAID | 1265467559 | 05 | NV | MEDICAID |