Basic Information
| Provider Information | |||||||||
| NPI: | 1912234618 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RICHARD BERNERT, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ARIZONA DERMATOPATHOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 11025 RCA CENTER DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PALM BEACH GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334104269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616265512 | ||||||||
| FaxNumber: | 5616264530 | ||||||||
| Practice Location | |||||||||
| Address1: | 9060 E VIA LINDA | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852585417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802069091 | ||||||||
| FaxNumber: | 4807724296 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2009 | ||||||||
| LastUpdateDate: | 04/13/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GRATTENDICK | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5616265512 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 31463 | AZ | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.