Provider Demographics
NPI:1508807116
Name:BERNTSON, MARK E (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:BERNTSON
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 1:320 EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:CROSBY
Mailing Address - State:MN
Mailing Address - Zip Code:56441
Mailing Address - Country:US
Mailing Address - Phone:218-546-7000
Mailing Address - Fax:218-546-4400
Practice Address - Street 1:30833 NORTH STAR DR. STE 1
Practice Address - Street 2:
Practice Address - City:BREZZY POINT
Practice Address - State:MN
Practice Address - Zip Code:56472-4407
Practice Address - Country:US
Practice Address - Phone:218-568-4926
Practice Address - Fax:218-546-4400
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5350207Q00000X
MN31661207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN500M5BEOtherBCBS
ND15352Medicaid
MN666588800Medicaid
D28553Medicare UPIN
MN080016336Medicare PIN
NDN711957Medicare ID - Type Unspecified
MN666588800Medicaid
MN500M5BEOtherBCBS
MN080014835Medicare ID - Type Unspecified
P00215198Medicare PIN