Provider Demographics
NPI:1710967989
Name:BERNTHAL, ALLEN C (MD)
Entity Type:Individual
Prefix:DR
First Name:ALLEN
Middle Name:C
Last Name:BERNTHAL
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 1:6827 STANLEY AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3287
Mailing Address - Country:US
Mailing Address - Phone:708-749-4617
Mailing Address - Fax:708-749-0094
Practice Address - Street 1:6827 STANLEY AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3287
Practice Address - Country:US
Practice Address - Phone:708-749-4617
Practice Address - Fax:708-749-0094
Is Sole Proprietor?:No
Enumeration Date:2006-01-22
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036054138174400000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036054138Medicaid
L22126Medicare ID - Type Unspecified
IL036054138Medicaid