Basic Information
Provider Information | |||||||||
NPI: | 1093184244 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BETHEL AVERBECK MD A PROFESSIONAL MEDICAL CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | VIRTUWELL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8170 33RD AVE S | ||||||||
Address2: | MAILSTOP 21110R | ||||||||
City: | MINNEAPOLIS | ||||||||
State: | MN | ||||||||
PostalCode: | 554254516 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9528837469 | ||||||||
FaxNumber: | 9528835395 | ||||||||
Practice Location | |||||||||
Address1: | 400 CAPITOL MALL | ||||||||
Address2: | 22ND FLOOR | ||||||||
City: | SACRAMENTO | ||||||||
State: | CA | ||||||||
PostalCode: | 958144407 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8774401001 | ||||||||
FaxNumber: | 6512651800 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/17/2015 | ||||||||
LastUpdateDate: | 09/30/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PALLATAO | ||||||||
AuthorizedOfficialFirstName: | KEVIN | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | VP | ||||||||
AuthorizedOfficialTelephone: | 9528835348 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.