Basic Information
| Provider Information | |||||||||
| NPI: | 1982688321 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERNEIKE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1250 E 3900 S | ||||||||
| Address2: | SUITE 260 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841241348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012652000 | ||||||||
| FaxNumber: | 8012652008 | ||||||||
| Practice Location | |||||||||
| Address1: | 1250 E 3900 S | ||||||||
| Address2: | SUITE 260 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841241348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012652000 | ||||||||
| FaxNumber: | 8012652008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2005 | ||||||||
| LastUpdateDate: | 06/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 3645941205 | UT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 870617263004/D2710 | 05 | UT | MEDICAID |