Provider Demographics
NPI:1699138230
Name:BERNARDINO, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:BERNARDINO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8111 HICKORY HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21060-8639
Mailing Address - Country:US
Mailing Address - Phone:571-490-4250
Mailing Address - Fax:
Practice Address - Street 1:8111 HICKORY HOLLOW DR
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21060-8639
Practice Address - Country:US
Practice Address - Phone:571-490-4250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-31
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD4580261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical