Provider Demographics
NPI:1548204985
Name:BERNETT, GARY B (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:B
Last Name:BERNETT
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 1:429 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:HAVERFORD
Mailing Address - State:PA
Mailing Address - Zip Code:19041-1009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 E STATE ST
Practice Address - Street 2:
Practice Address - City:KENNETT SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19348-3109
Practice Address - Country:US
Practice Address - Phone:610-925-4157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD019369E207RG0300X
NJ34994207RG0300X
CAG47355207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0005904350004Medicaid
022700OtherPA BCBS IND #
PA0005904350004Medicaid
022700OtherPA BCBS IND #