Provider Demographics
NPI:1750526570
Name:MEMBER, BERNARD (MD)
Entity type:Individual
Prefix:
First Name:BERNARD
Middle Name:
Last Name:MEMBER
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 1:103 W SENECA ST
Mailing Address - Street 2:SUITE 303C
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-4145
Mailing Address - Country:US
Mailing Address - Phone:804-339-2105
Mailing Address - Fax:
Practice Address - Street 1:103 W SENECA ST
Practice Address - Street 2:SUITE 303C
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-4145
Practice Address - Country:US
Practice Address - Phone:804-339-2105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-08
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1430642084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry