Provider Demographics
NPI:1366441925
Name:BERNSTEIN, GLENN IRA (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:IRA
Last Name:BERNSTEIN
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:PO BOX 278
Mailing Address - Street 2:
Mailing Address - City:WOODBURN
Mailing Address - State:OR
Mailing Address - Zip Code:97071
Mailing Address - Country:US
Mailing Address - Phone:971-983-5333
Mailing Address - Fax:971-983-5326
Practice Address - Street 1:406 WELCH ST
Practice Address - Street 2:
Practice Address - City:SILVERTON
Practice Address - State:OR
Practice Address - Zip Code:97381
Practice Address - Country:US
Practice Address - Phone:503-873-8853
Practice Address - Fax:503-873-8355
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN37327207V00000X
ORMD160464207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
4068112OtherBLUE CROSS OF TN
E59385Medicare UPIN
4068112OtherBLUE CROSS OF TN
3890499Medicare ID - Type Unspecified