Basic Information
| Provider Information | |||||||||
| NPI: | 1780053033 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARTIN KERNBERG MD INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JEFFERSON PAIN CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1327 WALLER ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941172920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074641989 | ||||||||
| FaxNumber: | 7074649593 | ||||||||
| Practice Location | |||||||||
| Address1: | 1225 MARSHALL ST | ||||||||
| Address2: | STE 18 | ||||||||
| City: | CRESCENT CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955312281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074641989 | ||||||||
| FaxNumber: | 7074649593 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2015 | ||||||||
| LastUpdateDate: | 09/16/2015 | ||||||||
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| AuthorizedOfficialLastName: | KERNBERG | ||||||||
| AuthorizedOfficialFirstName: | MARTIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7074641989 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 62629 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208VP0014X | 62629 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.