Basic Information
| Provider Information | |||||||||
| NPI: | 1952384505 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERNER | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | ELAINE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1110 OAKWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | OAKWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454192911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9378857163 | ||||||||
| FaxNumber: | 9375670670 | ||||||||
| Practice Location | |||||||||
| Address1: | 1110 OAKWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | OAKWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454192911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9378857163 | ||||||||
| FaxNumber: | 9375670670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2005 | ||||||||
| LastUpdateDate: | 07/17/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QG0300X | 35082769 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2428859 | 05 | OH | MEDICAID |