Provider Demographics
NPI:1598144768
Name:RAINBOW CHILDREN'S CLINIC MAYFIELD, PA
Entity Type:Organization
Organization Name:RAINBOW CHILDREN'S CLINIC MAYFIELD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:
Authorized Official - Last Name:BERNARDEZ-TAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:682-276-6700
Mailing Address - Street 1:1915 E MAYFIELD RD STE 115
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76014-2605
Mailing Address - Country:US
Mailing Address - Phone:682-276-6700
Mailing Address - Fax:682-276-6049
Practice Address - Street 1:1915 E MAYFIELD RD
Practice Address - Street 2:SUITE 115
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76014-2604
Practice Address - Country:US
Practice Address - Phone:682-276-6700
Practice Address - Fax:682-276-6049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-21
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8913208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX349462701Medicaid
TX1700084555OtherNPI
TX1225179039OtherNPI
TX1598709149OtherNPI
TX1083963631OtherNPI
TX1821357088OtherNPI
TX1053743948OtherNPI
TX1366881922OtherNPI