Provider Demographics
NPI:1124005202
Name:BERNEBURG, SCOTT WILLIAM (DPM)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:WILLIAM
Last Name:BERNEBURG
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 HARPER PARK DR
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-2617
Mailing Address - Country:US
Mailing Address - Phone:304-253-9895
Mailing Address - Fax:304-253-9896
Practice Address - Street 1:315 HARPER PARK DR
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-2617
Practice Address - Country:US
Practice Address - Phone:304-253-9895
Practice Address - Fax:304-253-9896
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV00325213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U62678Medicare UPIN
BE0824243Medicare ID - Type Unspecified