Basic Information
| Provider Information | |||||||||
| NPI: | 1508807116 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERNTSON | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 320 EAST MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | CROSBY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2185467000 | ||||||||
| FaxNumber: | 2185464400 | ||||||||
| Practice Location | |||||||||
| Address1: | 30833 NORTH STAR DR. STE 1 | ||||||||
| Address2: | |||||||||
| City: | BREZZY POINT | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564724407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2185684926 | ||||||||
| FaxNumber: | 2185464400 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 12/13/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/13/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5350 | ND | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 31661 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 500M5BE | 01 | MN | BCBS | OTHER | 15352 | 05 | ND | MEDICAID | 666588800 | 05 | MN | MEDICAID |