Provider Demographics
NPI:1609815398
Name:BERNIE, JAN EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:EDWARD
Last Name:BERNIE
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 1:60 E END AVE
Mailing Address - Street 2:APT 25B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-7907
Mailing Address - Country:US
Mailing Address - Phone:212-879-9474
Mailing Address - Fax:212-879-1994
Practice Address - Street 1:60 E END AVE
Practice Address - Street 2:APT 25B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-7907
Practice Address - Country:US
Practice Address - Phone:212-879-9474
Practice Address - Fax:212-879-1994
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35033087208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0164085Medicaid
0364694Medicare ID - Type Unspecified
A73582Medicare UPIN