Provider Demographics
NPI:1750349700
Name:BERTHA L. MEDINA MD PA
Entity type:Organization
Organization Name:BERTHA L. MEDINA MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BERTHA
Authorized Official - Middle Name:LAURA
Authorized Official - Last Name:RODRIGUEZ-MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:956-630-5585
Mailing Address - Street 1:721 SAVANNAH AVE
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78503-3006
Mailing Address - Country:US
Mailing Address - Phone:956-630-5585
Mailing Address - Fax:956-631-1372
Practice Address - Street 1:721 SAVANNAH AVE
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78503-3006
Practice Address - Country:US
Practice Address - Phone:956-630-5585
Practice Address - Fax:956-631-1372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-01
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
TXG-7102207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0805541-01Medicaid
TX0041BMMedicare PIN
TXD66965Medicare UPIN