Provider Demographics
NPI:1275523631
Name:BERNSEN, MITCHELL (MD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:BERNSEN
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 1:1415 S ARLINGTON HEIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-3765
Mailing Address - Country:US
Mailing Address - Phone:847-439-1005
Mailing Address - Fax:847-439-7555
Practice Address - Street 1:1415 S ARLINGTON HEIGHTS RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-3765
Practice Address - Country:US
Practice Address - Phone:847-439-1005
Practice Address - Fax:847-439-7555
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-084785207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-084785Medicaid
IL036-084785Medicaid
G24562Medicare UPIN
ILIL3511007Medicare PIN
634730Medicare ID - Type Unspecified
ILIL3509007Medicare PIN