Provider Demographics
NPI:1801987524
Name:BISMARK, BERND KLAUS (DC)
Entity type:Individual
Prefix:DR
First Name:BERND
Middle Name:KLAUS
Last Name:BISMARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6567
Mailing Address - Street 2:
Mailing Address - City:DIBERVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39540-6567
Mailing Address - Country:US
Mailing Address - Phone:228-861-3645
Mailing Address - Fax:228-392-1278
Practice Address - Street 1:15105 LEMOYNE BLVD
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-5201
Practice Address - Country:US
Practice Address - Phone:228-392-8616
Practice Address - Fax:228-392-1278
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS728111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00115421Medicaid
MS00115421Medicaid
MST21060Medicare UPIN