Provider Demographics
NPI:1811994858
Name:BERENS, BRUCE M (M D)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:M
Last Name:BERENS
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 4TH ST E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101-1421
Mailing Address - Country:US
Mailing Address - Phone:651-292-2043
Mailing Address - Fax:651-292-2204
Practice Address - Street 1:166 4TH ST E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-1421
Practice Address - Country:US
Practice Address - Phone:651-292-2043
Practice Address - Fax:651-292-2204
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN337312085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1811994858Medicaid
MN300003970Medicare PIN
MN1811994858Medicaid