Healthcare Provider Details

I. General information

NPI: 1316945405
Provider Name (Legal Business Name): BERNADETTE GENDERNALIK DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 03/17/2020
Certification Date: 03/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37399 GARFIELD RD STE 203 PROVIDER RETIRED
CLINTON TWP MI
48036
US

IV. Provider business mailing address

37399 GARFIELD RD STE 203 PROVIDER RETIRED
CLINTON TWP MI
48036
US

V. Phone/Fax

Practice location:
  • Phone: 586-228-2911
  • Fax:
Mailing address:
  • Phone: 586-228-2911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101009641
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: