Basic Information
| Provider Information | |||||||||
| NPI: | 1851333587 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERNSTEIN | ||||||||
| FirstName: | MARC | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | P.O. BOX 2209 | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | SLIDELL | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9856492700 | ||||||||
| FaxNumber: | 9856492950 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 GAUSE BLVD | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | SLIDELL | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9856492700 | ||||||||
| FaxNumber: | 9856492950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 07/18/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 016053 | LA | N | Other Service Providers | Specialist | 207RC0000X | 016053 | LA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 1357421 | 05 | LA | MEDICAID |