Provider Demographics
NPI:1083908081
Name:BETTS MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:BETTS MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAQUINTA
Authorized Official - Middle Name:L
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-327-6636
Mailing Address - Street 1:PO BOX 21790
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-0790
Mailing Address - Country:US
Mailing Address - Phone:248-967-1888
Mailing Address - Fax:248-967-1885
Practice Address - Street 1:21040 GREENFIELD RD
Practice Address - Street 2:STE 200
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-3025
Practice Address - Country:US
Practice Address - Phone:248-967-1888
Practice Address - Fax:248-967-1885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-07
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301040115207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
M15182Medicare PIN
0820527Medicare PIN