Basic Information
| Provider Information | |||||||||
| NPI: | 1699863936 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BETHESDA HEALTH PHYSICIAN GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2815 S SEACREST BLVD | ||||||||
| Address2: | ATTN: FINANCE | ||||||||
| City: | BOYNTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334357934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617377733 | ||||||||
| FaxNumber: | 5617335912 | ||||||||
| Practice Location | |||||||||
| Address1: | 2815 S SEACREST BLVD | ||||||||
| Address2: | ATTN: FINANCE | ||||||||
| City: | BOYNTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334357934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617377733 | ||||||||
| FaxNumber: | 5617335912 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 02/18/2014 | ||||||||
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| AuthorizedOfficialLastName: | PEED | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | JC | ||||||||
| AuthorizedOfficialTitleorPosition: | PROFESSIONAL ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5617377733 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2563126 | 05 | FL | MEDICAID |