Provider Demographics
NPI:1437318581
Name:BERNAL PEDIATRIC CLINIC
Entity Type:Organization
Organization Name:BERNAL PEDIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
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:956-630-4669
Mailing Address - Street 1:801 E NOLANA AVE
Mailing Address - Street 2:SUITE 11
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78504-6104
Mailing Address - Country:US
Mailing Address - Phone:956-630-4669
Mailing Address - Fax:956-668-7139
Practice Address - Street 1:801 E NOLANA AVE
Practice Address - Street 2:SUITE 11
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78504-6104
Practice Address - Country:US
Practice Address - Phone:956-630-4669
Practice Address - Fax:956-668-7139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-04
Last Update Date:2008-07-07
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
TXK3096OtherLICENSE NO.
TX0059DFOtherBLUE CROSS BLUE SHIELD PROV NO.
TX164872701Medicaid
TX164872702Medicaid
TXG04053OtherUPIN