Healthcare Provider Details

I. General information

NPI: 1245255207
Provider Name (Legal Business Name): JONATHAN MARK BERNHEIMER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 11/15/2021
Certification Date: 11/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PL DIV PED ACADEMICS, STE 2D
SAINT LOUIS MO
63110-1002
US

IV. Provider business mailing address

1 CHILDRENS PL MSC 8515-87-1200
SAINT LOUIS MO
63110-1002
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-6300
  • Fax: 833-969-0131
Mailing address:
  • Phone: 314-454-6300
  • Fax: 833-969-0131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2021027522
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: