Provider Demographics
NPI:1790882876
Name:BERNBLUM, NERIEL Y (MD)
Entity Type:Individual
Prefix:MR
First Name:NERIEL
Middle Name:Y
Last Name:BERNBLUM
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 1:120 W DUDLEY ST
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537
Mailing Address - Country:US
Mailing Address - Phone:419-893-1971
Mailing Address - Fax:419-893-2321
Practice Address - Street 1:120 W DUDLEY ST
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537
Practice Address - Country:US
Practice Address - Phone:419-893-1971
Practice Address - Fax:419-893-2321
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH38677207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0309428Medicaid
E61118Medicare UPIN
OHMA9917612Medicare ID - Type Unspecified