Basic Information
| Provider Information | |||||||||
| NPI: | 1952347908 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERNEBURG | ||||||||
| FirstName: | KURT | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4107 MEDICAL PKWY | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787563735 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5656 BEE CAVES RD BLDG C # 101 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123235465 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 02/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | K3684 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | K3684 | TX | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 0447674-01 | 05 | TX | MEDICAID | 044767401 | 05 | TX | MEDICAID |