Provider Demographics
NPI:1093184244
Name:BETHEL AVERBECK MD A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:BETHEL AVERBECK MD A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:VIRTUWELL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:PALLATAO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-883-5348
Mailing Address - Street 1:8170 33RD AVE S
Mailing Address - Street 2:MAILSTOP 21110R
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:952-883-7469
Mailing Address - Fax:952-883-5395
Practice Address - Street 1:400 CAPITOL MALL
Practice Address - Street 2:22ND FLOOR
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95814-4407
Practice Address - Country:US
Practice Address - Phone:877-440-1001
Practice Address - Fax:651-265-1800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-17
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty