Provider Demographics
NPI:1003198862
Name:BERNAL PEDIATRIC CLINIC
Entity Type:Organization
Organization Name:BERNAL PEDIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:E
Authorized Official - Last Name:BERNAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:956-519-4647
Mailing Address - Street 1:810 E VETERANS BLVD
Mailing Address - Street 2:SUITE H
Mailing Address - City:PALMVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:78572-5018
Mailing Address - Country:US
Mailing Address - Phone:956-519-4647
Mailing Address - Fax:956-519-4578
Practice Address - Street 1:810 E VETERANS BLVD
Practice Address - Street 2:SUITE H
Practice Address - City:PALMVIEW
Practice Address - State:TX
Practice Address - Zip Code:78572-5018
Practice Address - Country:US
Practice Address - Phone:956-519-4647
Practice Address - Fax:956-519-4578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-16
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK3096208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX219832701Medicaid
TX219832702Medicaid