Healthcare Provider Details

I. General information

NPI: 1649213554
Provider Name (Legal Business Name): MICHAEL M BERMUDEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 07/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3630 WILLOWCREEK RD
PORTAGE IN
46368-5075
US

IV. Provider business mailing address

149 RAINBOW DRIVE #4918
LIVINGSTON TX
77399-1049
US

V. Phone/Fax

Practice location:
  • Phone: 219-364-3000
  • Fax:
Mailing address:
  • Phone: 316-841-4324
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01061935A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number36266
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number208568
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0101241235
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: