Provider Demographics
NPI:1255397766
Name:BERNOTUS, ERVIN E (MD)
Entity type:Individual
Prefix:
First Name:ERVIN
Middle Name:E
Last Name:BERNOTUS
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 1:8625 54TH DR E
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34211-9456
Mailing Address - Country:US
Mailing Address - Phone:941-753-4400
Mailing Address - Fax:941-753-4408
Practice Address - Street 1:8625 54TH DR E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34211-9456
Practice Address - Country:US
Practice Address - Phone:941-753-4400
Practice Address - Fax:941-753-4408
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88550174400000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL48581OtherBCBS
FLU3452Z & U3452YMedicare ID - Type UnspecifiedTWO MEDICARE IDS
H67422Medicare UPIN
U3452XMedicare PIN