MEDICARE: ANDREW WILLIAM BERNAL MLT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246RM2200X	Medical Laboratory Technician	84666

General Provider Information

NPI Number	:	1134619653
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREW WILLIAM BERNAL MLT

Provider Business Mailing Address
First Line	:	1123 SABLE XING
Second Line	:
City	:	SUWANEE
State	:	GA
Zip	:	30024-3867
Country	:	US
Telephone Number	:	240-723-5779
Fax Number	:

Provider Business Practice Location Address
First Line	:	1700 CLAIRMONT RD
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30033-4032
Country	:	US
Telephone Number	:	240-723-5779
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/10/2018
Last Update Date	:	05/10/2018

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