Basic Information
| Provider Information | |||||||||
| NPI: | 1508045196 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BETHESDA PHYSICIAN SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 635839 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452630001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004433672 | ||||||||
| FaxNumber: | 8655607310 | ||||||||
| Practice Location | |||||||||
| Address1: | 8600 OLD GEORGETOWN RD | ||||||||
| Address2: | |||||||||
| City: | BETHESDA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208141422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018963593 | ||||||||
| FaxNumber: | 3018962359 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2007 | ||||||||
| LastUpdateDate: | 07/31/2012 | ||||||||
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| AuthorizedOfficialLastName: | LEONARD | ||||||||
| AuthorizedOfficialFirstName: | BARTON | ||||||||
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| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 3018963593 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 415835100 | 05 | MD | MEDICAID |