Provider Demographics
NPI:1164423620
Name:BERNING, KEVIN L (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:L
Last Name:BERNING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:260-266-6013
Mailing Address - Fax:
Practice Address - Street 1:11141 PARKVIEW PLAZA DR STE 300
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1715
Practice Address - Country:US
Practice Address - Phone:260-490-7111
Practice Address - Fax:260-490-2286
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2022-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01055645A2082S0105X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200377060Medicaid
MI104394511Medicaid
IN240007632Medicare PIN
IN186080IMedicare PIN
IN200377060Medicaid
INH42359Medicare UPIN
IN186080IMedicare PIN