Provider Demographics
NPI:1255424727
Name:BERNHEIM, PETER JOSEPH (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:JOSEPH
Last Name:BERNHEIM
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 1:4500 WEST RAILROAD STREET
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503
Mailing Address - Country:US
Mailing Address - Phone:228-864-5155
Mailing Address - Fax:228-864-4417
Practice Address - Street 1:4500 WEST RAILROAD STREET
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503
Practice Address - Country:US
Practice Address - Phone:228-864-5155
Practice Address - Fax:228-864-4417
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12089174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00112062Medicaid
MSE59515Medicare UPIN
MS100000049Medicare ID - Type Unspecified