Basic Information
| Provider Information | |||||||||
| NPI: | 1710967989 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERNTHAL | ||||||||
| FirstName: | ALLEN | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6827 STANLEY AVE | ||||||||
| Address2: | |||||||||
| City: | BERWYN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604023287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087494617 | ||||||||
| FaxNumber: | 7087490094 | ||||||||
| Practice Location | |||||||||
| Address1: | 6827 STANLEY AVE | ||||||||
| Address2: | |||||||||
| City: | BERWYN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604023287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087494617 | ||||||||
| FaxNumber: | 7087490094 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2006 | ||||||||
| LastUpdateDate: | 02/25/2015 | ||||||||
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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 | 174400000X | 036054138 | IL | N | Other Service Providers | Specialist | 207RG0100X | 036054138 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 036054138 | 05 | IL | MEDICAID |