Provider Demographics
NPI:1952663528
Name:JACK EDWARD BERNDT
Entity Type:Organization
Organization Name:JACK EDWARD BERNDT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:BERNDT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-808-2392
Mailing Address - Street 1:1957 THOMPSON RD
Mailing Address - Street 2:STE. F
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2031
Mailing Address - Country:US
Mailing Address - Phone:541-808-2392
Mailing Address - Fax:
Practice Address - Street 1:1957 THOMPSON RD
Practice Address - Street 2:STE. F
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2031
Practice Address - Country:US
Practice Address - Phone:541-808-2392
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty