Provider Demographics
NPI:1952384505
Name:BERNER, SUSAN ELAINE (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELAINE
Last Name:BERNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 OAKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:OAKWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45419-2911
Mailing Address - Country:US
Mailing Address - Phone:937-885-7163
Mailing Address - Fax:937-567-0670
Practice Address - Street 1:1110 OAKWOOD AVE
Practice Address - Street 2:
Practice Address - City:OAKWOOD
Practice Address - State:OH
Practice Address - Zip Code:45419-2911
Practice Address - Country:US
Practice Address - Phone:937-885-7163
Practice Address - Fax:937-567-0670
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-28
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35082769207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2428859Medicaid
OHBE4169712Medicare PIN
OH2428859Medicaid