Basic Information
Provider Information | |||||||||
NPI: | 1225327620 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BETTENDORF | ||||||||
FirstName: | JOSEPH | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 400 E 3RD ST | ||||||||
Address2: | ESSENTIA HEALTH DULUTH CLINIC MCL2CRED | ||||||||
City: | DULUTH | ||||||||
State: | MN | ||||||||
PostalCode: | 558051951 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2187868319 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 407 E 3RD ST | ||||||||
Address2: | ESSENTIA HEALTH ST. MARY'S MEDICAL CENTER | ||||||||
City: | DULUTH | ||||||||
State: | MN | ||||||||
PostalCode: | 558051950 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2187864000 | ||||||||
FaxNumber: | 5854733516 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/06/2011 | ||||||||
LastUpdateDate: | 02/17/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 60993 | MN | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | 66319-20 | WI | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
No ID Information.