Provider Demographics
NPI:1386704435
Name:BERNARDO, FIDEL RELLAMA (PT)
Entity type:Individual
Prefix:MR
First Name:FIDEL
Middle Name:RELLAMA
Last Name:BERNARDO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:452 EXETER CT
Mailing Address - Street 2:
Mailing Address - City:GALLOWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08205-6682
Mailing Address - Country:US
Mailing Address - Phone:609-965-9552
Mailing Address - Fax:609-965-9553
Practice Address - Street 1:714 W WHITE HORSE PIKE
Practice Address - Street 2:SUITE B
Practice Address - City:EGG HARBOR CITY
Practice Address - State:NJ
Practice Address - Zip Code:08215-3838
Practice Address - Country:US
Practice Address - Phone:609-965-9552
Practice Address - Fax:609-965-9553
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00921400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2342235000OtherAMERIHEALTH
NJ056072TYGMedicare ID - Type Unspecified