Provider Demographics
NPI:1215914395
Name:SCOTT W BERNEBURG DPM INC
Entity type:Organization
Organization Name:SCOTT W BERNEBURG DPM INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:BERNEBURG
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:304-253-9895
Mailing Address - Street 1:315 HARPER PARK DR
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-2617
Mailing Address - Country:US
Mailing Address - Phone:304-253-9895
Mailing Address - Fax:304-253-9896
Practice Address - Street 1:315 HARPER PARK DR
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-2617
Practice Address - Country:US
Practice Address - Phone:304-253-9895
Practice Address - Fax:304-253-9896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-29
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV00325213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001706128OtherMOUNTAIN STATE BC BS
WADG1411OtherRAILROAD MEDICARE
WADG1411OtherRAILROAD MEDICARE
WV001706128OtherMOUNTAIN STATE BC BS