Basic Information
| Provider Information | |||||||||
| NPI: | 1255344867 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BETLEY | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | JEROME | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3621 S STATE ST | ||||||||
| Address2: | 700 KMS PLACE | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349362047 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 EAST MEDICAL CENTER DR | ||||||||
| Address2: | 1H247 UNIVERSITY HOSPITAL | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481095048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349364280 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 02/06/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 4704130400 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 104486328 | 05 | MI | MEDICAID | KB130400 | 01 | MI | BLUE CROSS OF MI | OTHER | 430079560 | 01 | MI | RAILROAD MEDICARE | OTHER |