Provider Demographics
NPI:1750367405
Name:NEWBERRY FAMILY HEALTH CENTER PA
Entity type:Organization
Organization Name:NEWBERRY FAMILY HEALTH CENTER PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:BERNARDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-924-1152
Mailing Address - Street 1:1109 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:NEWBERRY
Mailing Address - State:SC
Mailing Address - Zip Code:29108-3443
Mailing Address - Country:US
Mailing Address - Phone:803-321-3035
Mailing Address - Fax:803-321-3034
Practice Address - Street 1:2306 HARRINGTON ST STE 1
Practice Address - Street 2:
Practice Address - City:NEWBERRY
Practice Address - State:SC
Practice Address - Zip Code:29108-3088
Practice Address - Country:US
Practice Address - Phone:803-321-3035
Practice Address - Fax:803-321-3034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-15
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1844Medicaid
SC=========OtherGROUP TAX ID #
SC5649Medicare PIN