Healthcare Provider Details

I. General information

NPI: 1508942640
Provider Name (Legal Business Name): GREGORY BERNARDO PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 03/01/2024
Certification Date: 03/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44201 DEQUINDRE ROAD
TROY MI
48085-6769
US

IV. Provider business mailing address

26901 BEAUMONT BLVD SUITE 3D
SOUTHFIELD MI
48033-3849
US

V. Phone/Fax

Practice location:
  • Phone: 248-964-4866
  • Fax: 248-964-4848
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601004661
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: