Provider Demographics
NPI:1760596969
Name:PERMIAN NEPHROLOGY ASSOCIATES, PA
Entity Type:Organization
Organization Name:PERMIAN NEPHROLOGY ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BERNAL
Authorized Official - Suffix:
Authorized Official - Credentials:RHIT, RMA
Authorized Official - Phone:432-522-2304
Mailing Address - Street 1:P O BOX 80279
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79708-0279
Mailing Address - Country:US
Mailing Address - Phone:432-522-2304
Mailing Address - Fax:432-522-2307
Practice Address - Street 1:3302 W GOLF COURSE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79703-5110
Practice Address - Country:US
Practice Address - Phone:432-522-2304
Practice Address - Fax:432-522-2307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1867207RN0300X
TXG5429207RN0300X
TX630161363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX084735202Medicaid
TX0847352-02Medicaid
CN3681OtherRAILROAD MEDICARE
TX084735202Medicaid
TX0847352-02Medicaid
D97588Medicare UPIN