=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407824576
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAURICE R BERNAICHE D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2006
-----------------------------------------------------
Last Update Date | 12/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 GORDON AVE
-----------------------------------------------------
City | THOMASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31792-6646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-765-8623
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1401 OVEN PARK DR STE 201
-----------------------------------------------------
City | TALLAHASSEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32308-7958
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-765-8623
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2081S0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Physical Medicine & Rehabilitation) Physician
-----------------------------------------------------
License Number | 54547
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number | OS20454
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number | 54547
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------