Basic Information
| Provider Information | |||||||||
| NPI: | 1760596969 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PERMIAN NEPHROLOGY ASSOCIATES, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | P O BOX 80279 | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797080279 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4325222304 | ||||||||
| FaxNumber: | 4325222307 | ||||||||
| Practice Location | |||||||||
| Address1: | 3302 W GOLF COURSE RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MIDLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797035110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4325222304 | ||||||||
| FaxNumber: | 4325222307 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 02/24/2012 | ||||||||
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| AuthorizedOfficialLastName: | BERNAL | ||||||||
| AuthorizedOfficialFirstName: | THERESA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4325222304 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RHIT, RMA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | G5429 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 363LF0000X | 630161 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207RN0300X | F1867 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 084735202 | 05 | TX | MEDICAID | 0847352-02 | 05 | TX | MEDICAID | CN3681 | 01 | RAILROAD MEDICARE | OTHER |