Basic Information
| Provider Information | |||||||||
| NPI: | 1548204985 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERNETT | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 429 COLLEGE AVE | ||||||||
| Address2: | |||||||||
| City: | HAVERFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190411009 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 101 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | KENNETT SQUARE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193483109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109254157 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 09/17/2010 | ||||||||
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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 | 207RG0300X | MD019369E | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207RG0300X | 34994 | NJ | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207RG0300X | G47355 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0005904350004 | 05 | PA | MEDICAID | 022700 | 01 | PA BCBS IND # | OTHER |