Provider Demographics
NPI:1316945405
Name:GENDERNALIK, BERNADETTE (DO)
Entity type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:
Last Name:GENDERNALIK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37399 GARFIELD RD STE 203
Mailing Address - Street 2:PROVIDER RETIRED
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48036
Mailing Address - Country:US
Mailing Address - Phone:586-228-2911
Mailing Address - Fax:
Practice Address - Street 1:37399 GARFIELD RD STE 203
Practice Address - Street 2:PROVIDER RETIRED
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48036
Practice Address - Country:US
Practice Address - Phone:586-228-2911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009641207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4392670Medicaid
MIE33127Medicare UPIN
MI0N47480005Medicare ID - Type Unspecified