Provider Demographics
NPI:1235204397
Name:BERNDTSON, KEITH (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:BERNDTSON
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 1:15 N PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-3785
Mailing Address - Country:US
Mailing Address - Phone:847-232-9800
Mailing Address - Fax:847-232-8910
Practice Address - Street 1:15 N PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-3563
Practice Address - Country:US
Practice Address - Phone:847-232-9800
Practice Address - Fax:847-232-8910
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-067274207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC49849Medicare UPIN