MEDICARE: BERNITSKY VISION PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QS0132X	Ophthalmologic Surgery Clinic/Center	88-122	NM

General Provider Information

NPI Number	:	1922343888
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BERNITSKY VISION PC

Provider Business Mailing Address
First Line	:	6401 HOLLY AVE NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87113-2474
Country	:	US
Telephone Number	:	505-323-0800
Fax Number	:	505-323-6221

Provider Business Practice Location Address
First Line	:	6401 HOLLY AVE NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87113-2474
Country	:	US
Telephone Number	:	505-323-0800
Fax Number	:	505-323-6221

Authorized Official
Title or Position	:	BUSINESS OFFICE MANAGER
Name	:	JACQUI DONNELL
Credential	:
Telephone Number	:	505-323-0800

Provider Enumeration Date	:	12/04/2012
Last Update Date	:	12/04/2012

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