Provider Demographics
NPI:1912234618
Name:RICHARD BERNERT, LLC
Entity Type:Organization
Organization Name:RICHARD BERNERT, LLC
Other - Org Name:ARIZONA DERMATOPATHOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:GRATTENDICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-626-5512
Mailing Address - Street 1:11025 RCA CENTER DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-4269
Mailing Address - Country:US
Mailing Address - Phone:561-626-5512
Mailing Address - Fax:561-626-4530
Practice Address - Street 1:9060 E VIA LINDA
Practice Address - Street 2:SUITE 150
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-5417
Practice Address - Country:US
Practice Address - Phone:480-206-9091
Practice Address - Fax:480-772-4296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-17
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31463291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ134074Medicare PIN