Provider Demographics
NPI:1073808705
Name:COHEN, BETHANY R (MD)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:R
Last Name:COHEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 ST LIAM HALL
Mailing Address - Street 2:
Mailing Address - City:NOTRE DAME
Mailing Address - State:IN
Mailing Address - Zip Code:46556-5693
Mailing Address - Country:US
Mailing Address - Phone:574-631-7497
Mailing Address - Fax:574-631-6047
Practice Address - Street 1:107 ST LIAM HALL
Practice Address - Street 2:
Practice Address - City:NOTRE DAME
Practice Address - State:IN
Practice Address - Zip Code:46556-5693
Practice Address - Country:US
Practice Address - Phone:574-631-7497
Practice Address - Fax:574-631-6047
Is Sole Proprietor?:No
Enumeration Date:2011-06-10
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01071880A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201110970Medicaid
INP01439664Medicare PIN
IN255710002Medicare PIN