Basic Information
| Provider Information | |||||||||
| NPI: | 1447248232 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERNARDINO | ||||||||
| FirstName: | EVENTURE | ||||||||
| MiddleName: | DULDULAO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 501 LAPEER | ||||||||
| Address2: | HEALTH DELIVERY INC | ||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486071208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897596464 | ||||||||
| FaxNumber: | 9893998233 | ||||||||
| Practice Location | |||||||||
| Address1: | 6297 DIXIE HWY | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487229635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897596460 | ||||||||
| FaxNumber: | 9897596465 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2005 | ||||||||
| LastUpdateDate: | 04/08/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301068741 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080G310660 | 01 | MI | BCBS | OTHER | 0985019 | 01 | HEALTHPLUS OF MICHIGAN | OTHER | 1010674 | 01 | MCLAREN HEALTH PLAN | OTHER | 1010674 | 01 | HEALTH ADVANTAGE PPO | OTHER | 11812 | 01 | GREAT LAKES HEALTH PLAN | OTHER | 159 | 01 | MI | COMMUNITY CHOICE | OTHER | 5128736 | 01 | AETNA | OTHER | P101711 | 01 | BLUE CARE NETWORK OF MICH | OTHER | 080179045 | 01 | RAILROAD MEDICARE | OTHER | 1447248232 | 05 | MI | MEDICAID | 381908328 | 01 | UNDER | OTHER | 4336750 | 01 | MOLINA HEALTH CARE OF MIC | OTHER | 381908328 | 01 | HCAP | OTHER | 381908328 | 01 | FIRST HEALTH | OTHER | 381908328 | 01 | PPOM | OTHER | 4336750 | 05 | MI | MEDICAID |