Provider Demographics
NPI:1639787914
Name:AUGUSTIN, BERMANN
Entity Type:Individual
Prefix:
First Name:BERMANN
Middle Name:
Last Name:AUGUSTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3303 S KESWICK PLZ
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19114-1677
Mailing Address - Country:US
Mailing Address - Phone:267-461-4340
Mailing Address - Fax:
Practice Address - Street 1:3303 S KESWICK PLZ
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-1677
Practice Address - Country:US
Practice Address - Phone:267-461-4340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-22
Last Update Date:2022-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20-292246ZC0007X
PR001457-P.A.363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20-292Medicaid