Healthcare Provider Details

I. General information

NPI: 1770088551
Provider Name (Legal Business Name): AMANDA MARIE BERNARD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2018
Last Update Date: 08/11/2021
Certification Date: 08/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 WOODLAND AVE
PHILADELPHIA PA
19143-5137
US

IV. Provider business mailing address

31070 SIKON ST
CHESTERFIELD MI
48047-4683
US

V. Phone/Fax

Practice location:
  • Phone: 888-296-4742
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD474459
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: