Healthcare Provider Details

I. General information

NPI: 1538156377
Provider Name (Legal Business Name): ROBERT MARC BERNHOLC MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 05/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 E GATE LN
SETAUKET NY
11733-1645
US

IV. Provider business mailing address

13 E GATE LN
SETAUKET NY
11733-1645
US

V. Phone/Fax

Practice location:
  • Phone: 631-941-9757
  • Fax: 631-941-9757
Mailing address:
  • Phone: 631-941-9757
  • Fax: 631-941-9757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number1648481
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: