Basic Information
| Provider Information | |||||||||
| NPI: | 1245473313 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BETHEL INTERNAL MEDICINE AND PEDIATRICS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 713013 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432713013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137349200 | ||||||||
| FaxNumber: | 5137349300 | ||||||||
| Practice Location | |||||||||
| Address1: | 720 W PLANE ST | ||||||||
| Address2: | |||||||||
| City: | BETHEL | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451068339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137349200 | ||||||||
| FaxNumber: | 5137349300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2009 | ||||||||
| LastUpdateDate: | 07/29/2011 | ||||||||
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| AuthorizedOfficialLastName: | EVERSON | ||||||||
| AuthorizedOfficialFirstName: | CURTIS | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5137349200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2944587 | 05 | OH | MEDICAID | DP7944 | 01 | RR MEDICARE | OTHER |