Provider Demographics
NPI:1720066483
Name:BERN, MERRITT JONATHAN (MD)
Entity Type:Individual
Prefix:
First Name:MERRITT
Middle Name:JONATHAN
Last Name:BERN
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 1:3 RIVERSIDE CIR
Mailing Address - Street 2:CARILION CLINIC GASTROENTEROLGY RIVERSIDE 3
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24016-4955
Mailing Address - Country:US
Mailing Address - Phone:540-224-5170
Mailing Address - Fax:540-985-9418
Practice Address - Street 1:3 RIVERSIDE CIR
Practice Address - Street 2:CARILION CLINIC GASTROENTEROLGY RIVERSIDE 3
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-4955
Practice Address - Country:US
Practice Address - Phone:540-224-5170
Practice Address - Fax:540-985-9418
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101040654207RG0100X
IN01080690A207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVA900AOtherMEDICARE PTAN
100009137OtherMC RAIL ROAD
VA006097839Medicaid
260856OtherANTHEM
VAVVA900AOtherMEDICARE PTAN
B05685Medicare UPIN