Healthcare Provider Details

I. General information

NPI: 1952384505
Provider Name (Legal Business Name): SUSAN ELAINE BERNER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2005
Last Update Date: 07/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 OAKWOOD AVE
OAKWOOD OH
45419-2911
US

IV. Provider business mailing address

1110 OAKWOOD AVE
OAKWOOD OH
45419-2911
US

V. Phone/Fax

Practice location:
  • Phone: 937-885-7163
  • Fax: 937-567-0670
Mailing address:
  • Phone: 937-885-7163
  • Fax: 937-567-0670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number35082769
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: