Basic Information
| Provider Information | |||||||||
| NPI: | 1659315349 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERNEKING | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 436 44TH ST SE STE A | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495484371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6165319750 | ||||||||
| FaxNumber: | 6165319710 | ||||||||
| Practice Location | |||||||||
| Address1: | 436 44TH ST SE STE A | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495484371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6165319750 | ||||||||
| FaxNumber: | 6165319710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 05/11/2009 | ||||||||
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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 | 4301071005 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 01058986A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200836290 | 05 | IN | MEDICAID | 0807500681 | 01 | MI | BCBS | OTHER | 000000497920 | 01 | IN | ANTHEM | OTHER |