Basic Information
| Provider Information | |||||||||
| NPI: | 1225007388 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BETTERIDGE | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9505 S STEELE ST | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984441858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535976800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2721 SOUNDVIEW DR W | ||||||||
| Address2: | |||||||||
| City: | UNIVERSITY PLACE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984661725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532839954 | ||||||||
| FaxNumber: | 2532839954 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 05/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204C00000X | 2948311205 | UT | N | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine, Sports Medicine | 204C00000X | MD00043643 | WA | N | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine, Sports Medicine | 207PS0010X | 294831-1205 | UT | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Sports Medicine | 207PS0010X | MD00043643 | WA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 942854058788-D6149 | 05 | UT | MEDICAID |