Provider Demographics
NPI:1427035716
Name:EDEN, BERNARD (MD)
Entity Type:Individual
Prefix:
First Name:BERNARD
Middle Name:
Last Name:EDEN
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 1:2520 ELISHA AVE
Mailing Address - Street 2:
Mailing Address - City:ZION
Mailing Address - State:IL
Mailing Address - Zip Code:60099-2676
Mailing Address - Country:US
Mailing Address - Phone:847-872-4561
Mailing Address - Fax:
Practice Address - Street 1:2 W CRESCENT PARK
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:PA
Practice Address - Zip Code:16365-2111
Practice Address - Country:US
Practice Address - Phone:814-723-7906
Practice Address - Fax:814-723-0414
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
PAMD4370682085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF77473Medicare UPIN
ILL90801Medicare ID - Type UnspecifiedMEDICARE #