Basic Information
| Provider Information | |||||||||
| NPI: | 1962790709 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BETHEL | ||||||||
| FirstName: | KRISTINA | ||||||||
| MiddleName: | JO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SIKES | ||||||||
| OtherFirstName: | KRISTINA | ||||||||
| OtherMiddleName: | JO | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 105 CONCORD PL | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391107541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3059789769 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2500 N STATE ST | ||||||||
| Address2: | UNIVERSITY OF MISSISSIPPI MEDICAL CENTER | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019845582 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2011 | ||||||||
| LastUpdateDate: | 06/29/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | T-2507 | MS | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.