Provider Demographics
NPI:1164634267
Name:RAY, BERNADETTE (MD)
Entity Type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:
Last Name:RAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1120 N MELVIN ST
Mailing Address - Street 2:
Mailing Address - City:GIBSON CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60936-1477
Mailing Address - Country:US
Mailing Address - Phone:217-379-4864
Mailing Address - Fax:217-379-2124
Practice Address - Street 1:227 N MARKET ST
Practice Address - Street 2:
Practice Address - City:PAXTON
Practice Address - State:IL
Practice Address - Zip Code:60957-1123
Practice Address - Country:US
Practice Address - Phone:217-379-4864
Practice Address - Fax:217-379-2124
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036121344207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370647938006Medicaid